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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 /> �,0,�. PO Box 66
<br /> � ,, � Crystal Bay, MN 55323-0066 Date received:
<br /> a �j���'�,� :: �,;� StreetAddress: Receivedby:
<br /> 's'�,L,�� f�`�,_ Gtiti 2750 Kelley Parkway Plan review fee:
<br /> .�� ���¢�� Orono, MN 55356
<br /> kESII�
<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: ,_ " , � �';r,c��� ,�� �
<br /> Job Site Address: ���L �- �-' �- '� r"�' r � � `- , `' 2
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes [�-N6
<br /> If yes,a special event permit is required with Police Department and City Council approval 60 days pnor to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APP ANT INF ATION:
<br /> Name:
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (office) (cell)
<br /> Mailing Address: City: ZIP:
<br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: )��)���,�,-:-r, ��'� 1'I'��!"]
<br /> Phone(day) ;c •' s,(�c��to�`7�.J ��s._d, - �J�`/-- (:�i ;> r' �v')
<br /> Address: �i; ,,.1, L� J=���,5 ;,>.� y: � �'�. �.i`-._ ZIP: �-� �'�%/
<br /> �/k,r-¢__- C it
<br /> Emailand/orFax l'r� . ;r _G,��., �n �w �:�.r �i ;' '�. <<r��
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> �l: ' MCWD review&permits:
<br /> [�}Door(s) `f`�' ❑ Remodel ❑Water Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> 0'�Nindow(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd
<br /> [�iding ❑ Restoration ,�'Other: (specify) Deephaven, MN 55391
<br /> - Phone: 952-471-0590
<br /> ❑ Re-roof ❑ Fire Damage ����� �"`�� �`r��� Fax: 952-471-0682
<br /> www.minnehahacreek.orq
<br /> Overall Project Description: �JZ �.� . r�� � � , �� ,�<:���s ! �� ,%�,,zi, ,,- -:�k6_ ,�� � ,.� .a ,� �:,�,,_ �-E-,.
<br /> Estimated Construction Valuation of Project(excluding land) $ ,;- �,,,
<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 /> confdential. 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 refuse to su I the information,the a �ication ma not be issued.
<br /> ApplicanYs Signature: � / � �-��� r�'-=��� !.`�����i��^�,�� Date: ��" �� ✓�=� //
<br /> �
<br /> Last Updated: 03-01-2011
<br /> (� �� `.�""`� LS 5✓�-- �l�la L + nrs� 4�
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