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<br /> City of Orono
<br /> Building Permit Application for Internal Work �
<br /> �
<br /> z� (windows, doors, siding, re-roof, etc.) ��
<br /> ' Mailing Address: Q/Q—jj b /�,
<br />� �v 0 PO Box 66 Permit number: 7`'7 �
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<br /> ,' Q n,� � Crystal Bay, MN 55323-0066 Date received: �(O /� ;�
<br /> � �� ���'.` s,� Street Address: Received by:
<br />�+' �'� ' q� �� 2750 Kelley Parkway Plan review fee:
<br />���� �`�kEsxoQ`'� Orono, MN 55356 ,�,( p,
<br />�x�' Total Fee: �Y � l(,O,�.�
<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: f� T ��
<br />���; Job Site Address: g�L% �- L.(�l � '� ` � �� Ct,C E' �.o i�� �.Ct_,�'�P i'3-►cv ���5 3 S� �
<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. Shuttfe bus service wiN be
<br />;t; required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />�,,..;
<br />;4j CONTRACTOR/APPLICANT INFORMATION: � �
<br />��, ►vame: I�i-YVvl,c�ll�lrt'T�'ob tf'i��` t-�t�„S(.,�lC�.�l. 'C.�� �v�c: �'i
<br />,.�.:
<br /> ;� State License# �3�� Expiration Date: �- 3�—�o Gi
<br />�y. Phone: -7� 3-`f7 3�- 3 3 %�7 (office) (���-7I�'-C�-�3� (cell) �.
<br />�k Mailing Address: � 7�a.5 �i� /�c�o? `� CitY ��ynnuu�� ZIP: .;5 c�cy 7
<br />�� Contact Person: Ket-�f� ' Applicant is: --e ractor / Homeowner
<br /> � (CirGe One)
<br />���_' Email and/or Fax:
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<br />�a PROPERTY OWNER INFORMATION:
<br />��' Name: � lC�� ���— �P`r���
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<br /> , Phone (day): �j��-�j 3d- 3�{��
<br /> Address: ��U�j ���,�; ��C� c�ty:l�c�vlc � ziP: SS ���,
<br />�;;:" Email and/or Fax �
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<br />�$. PROJECT INFORMATION:
<br /> � T e of Pro'ect:
<br />�•:.:;
<br /> YP 1 Any earth movement may require
<br /> '. MCWD review&permits
<br />�,:{; ❑ Door(s) ❑ Remodel ❑Water Damage
<br />� :
<br />�� Minnehaha Creek Watershed District(MCWD)
<br />�M� ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br />�':; Deephaven, MN 55391
<br />;;�;`, ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590
<br />��;
<br /> Re-roof Fax: 952-471-0682
<br />�< � ❑ Fire Damage www.minnehahacreek.orq
<br />�� Overall Project Description:'t��2��jZ�� �� 3�� �� Sht r�s�e�s� 'S�� �f!'te✓� � �
<br />��; Estimated Construction Valuation of Project(excluding land) ��j
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<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 />�.,
<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 />�`�."
<br /> fi��-� • 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 enerall cannot be iven to the ublic but can be iven to the sub ect of the
<br />� �, 9 Y 9� P 9� 1
<br />� ; data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<br /> y�,;; 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 refuse to su I the information,t a I� io a not be issued.
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<br />�;; ApplicanYs Signature: Date: �l�
<br />��; �.
<br />�,�. Last Updated: 05-04-2009 �
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