Laserfiche WebLink
City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: Q—�7 � <br /> g,�,�. PO Box 66 � / <br /> 0 =:�� 0 <br /> Crystal Bay, MN 55323-0066 Date received: �� �:�//� <br /> ��„���' - Received by: <br /> a f��{;,,�_+,� �, Street Address: <br /> �'�,c, .� y �'"`� �~ 2750 Kelley Parkway Plan review fee: <br /> t'�gESH�`,� 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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: `���� �,..c;�.����h�ic` /�vL _ �`�,��G <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> lf yes,a special event permit is required with Police Deparfinent and City Council approval 60 days prior 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/APPLICANT INFORMATION: <br /> Name: �._ - ��'���� ���v �CE� �--LL <br /> State License# `�r,�_ c��,�-��.� Expiration Date: � j'�_��� <br /> Phone: �'S1 •-'i�� . i��f-7 X \ � (office) Cv�'�2 -2�te� �Z-3�: (cell) <br /> Mailing Address: ` �, k� _� '. City: S� t��:` ZIP: ��1c�cc, <br /> Contact Person: E, Applicant is: on ractor- / Homeowner (Circle One) <br /> Email and/or Fax: �E�� � .-Z � � _ ��-7 � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �oSS -3 ��\"c-� c�� Qj v r.�ti� <br /> Phone (day): lp i 2.�i�� � . la�4 � <br /> Address: �b��� L-�;�v�r,` L.�.�.�� �;,,_ f� � � City: � r .�,�� ZIP: `�5 3�;,4 <br /> Email and/or Fax ��,SS 4� r��vr Ca i� � ;,;� t , Lc_�-� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> [�Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ `Z. 3 p p •`-' 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 pub.lic 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 lication ma not be issued. <br /> . -� -- ''.� i <br /> , - <br /> Applicant's Signature: � - Date: �O (7 - (Q <br /> Last Updated: 05-04-2009 <br />