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City of Orono
<br /> Building Permit Application for Internal Work
<br /> ., (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> O�v�,�0 PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> � � -�i �, � Street Address: Received by: S � � � �S l�,�.
<br /> �'� `'� � �titi 2750 Kelley Parkway Plan review fee: (
<br /> t'�ESHog� Orono, MN 55356
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: " " " � , , � `', � .
<br /> ,�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicanf demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR I APPLICANT INFaR�IATION:
<br /> �
<br /> Name: �,.'�,'� ,, � -�; � �
<br /> a�
<br /> State License# � �.,, �- , ' Expiration Date: �_; 3 ' ��.;
<br /> �
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that w�re construcfed prior to 1978
<br /> Phone: ` � � `>� "'., >r-�� (office) (cell)
<br /> Mailin Address: , S�- � �,� ( ��,.� City: �r' �:� . �� ZIP: S'�;• �
<br /> 9 ,�14� � c� i - ,
<br /> � � � _�
<br /> Contact Person: �7 � Applicant is: Contractor / Homeowner (CirGe One)
<br /> Email andbr Fax: <-,\,,_,\ �,n� ,-,� ,-._. �C;��,�„��� - ('_ C,','�---
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: '�,
<br />, Phone (day):
<br /> Address: ,\,� `�- � L: �� >�,C.c �� City: ;, ; ZIP: : `3� (,�
<br /> ��
<br /> Email and/or Fax ���� �=�l��7�� ��� 7 �� �
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑ Door(s) ❑ Rerx�ode� ❑Water Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) �epairl�c � �� ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Siding ❑ Restoration ❑ Other. (specify) Deephaven, MN 55391
<br /> Ph one: 952-471-0590
<br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682
<br /> www.minnehahacreek.orq
<br /> Overall Project Description: �,- < < � �� c I ; -��� � ��/<! �! C. ��'� �`�._ �
<br /> Estimated Construction Valuation of Project(excluding land) $ �,-,c �'`�'
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br /> but to reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies
<br /> re uired b law. If ou refu o su I the information, the a lication ma not be issued.
<br /> � c� ZS— �/
<br /> ApplicanYs Signature: � - Date:
<br /> Last Updated: 03-01-2011
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