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<br />} City of Orono
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<br />- � Building Permit Application for Internal Work
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<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> 'gv�,� PO Box 66
<br /> Q �\ Q Crystal Bay, MN 55323-0066 Date received:
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<br /> � Received b '
<br /> �� ������-:", �,'� Street Address: y�
<br /> �n ° �„� �� 2750 Kelley Parkway Plan review fee:
<br /> t�'kESH 4'� 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: �;".,� �' ��>>, L��� j�J�,��/ �
<br /> Will this be a Parade of Homes, Remodeler Showcase Home or other Display Home? ❑ Yes QNo $�
<br /> /f yes, a specia/event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shutt/e bus service wi/l 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: �c-� �aS ti�.,G� �
<br /> State License# '
<br /> Expiration Date: .��
<br /> Phone: � z;-��' C- �� •- � office cell �
<br /> Mailing Address: V � � �; - • ` City: �,'�'vy� � ZIP: �,' �
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<br /> Contact Person: " r,a -S � ,. Applicant is: Contractor �� ' Homeowner ��cle One) ��
<br /> Email and/or Fax: c �� , l c� ��f.l v � � ' / < <�.�-. `�. _. .�- ��
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<br /> PROPERTY OWNER INFORMATION: ��
<br /> Name: ! � ri� Cf 4:S Li�.x���,.� ;��
<br /> Phone (day): L:� � ? _ �/�s<_�','7 `�'�"� �, �
<br /> Address: ��--���,' /.,,,,/6,.�____�fiLa!' City: ��^�6� ZIP: ��Z-� �
<br /> Email and/or Fax , , . ,�� ^ �, ,�
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<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 �y�
<br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 ��
<br /> Fax: 952-471-0682 �
<br /> [�'Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> �
<br /> Overall Project Description: �
<br /> Estimated Construction Valuation of Project(excluding land) $ � �i�'�(+� � C�j �
<br /> �?�
<br /> APPLICANT ACKNOWLEDGEMENT: �
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<br /> • Agrees to provide all information required or requested by the Building Department; �:`�
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<br /> • Certifies that the information supplied is true and correct to the best of hislher knowledge. The applicant recognizes that they n
<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 refuse to su I the information,the a lication ma not be issued.
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<br /> � ApplicanYs Signature: � � " � m�,r �--- Date: ��i
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<br /> 4 �, Last Updated: 05-04-2009 :1 ;
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