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<br /> � City of Orono ����s�r:
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<br /> Building Permit Application for Internal Work ��'3+�� ���`
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<br />�,,� (windows, doors, siding, re-roof, etc.)
<br />��� Mailing Address: �
<br /> � �v 0� PO Box 66 Permit number: p�d Q-��7� �
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<br />��k Q � Crystal Bay, MN 55323-0066 Date received: .> /!7 ��
<br />�����': ,� ��' -���` a StreetAddress: Received by: ��
<br /> � F`� !4 ��%,
<br />�'.; �'� '`� q� Gti 2750 Kelley Parkway Plan review fee:
<br /> L�kESH�g'� Orono, MN 55356 -
<br />�4`-� 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) s`�°
<br />�,' GENERAL INFORMATION: �>
<br />�_:� Job Site Address: %��''L�,� �,� ��,f , - �� �_,
<br /> �
<br />�"�: Will this be a Parade of Homes, Remodeler Showcase Home or other Display Home? ❑ Yes ❑ No �
<br />�y� 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 /> re uired unless a licant demonstrates sufficient on-site arkin �s available. Non- ermitted events will not be allowed.
<br />�: 4 PP P 9 P
<br />� CONTRACTOR/APPLICANT INFORMATION:
<br />� �,��� �,��. �
<br /> � Name: .
<br />� State License# �pp/�—p �� � Expiration Date: s �^,�j-� //
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<br />� Phone: - (office cell � .,rp�
<br /> Mailin Address: Cit : �
<br />��; 9 �o-. . ZIP: �S"�o9 v6�.1'
<br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: ���-7�y-� /�7j
<br /> �
<br /> PROPERTY OWNER NFORMATION: �
<br /> Name: _ �� �q��
<br />����� Phone da �
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<br />��$ Address: ����„� �e� �o,�, City: ;.��,Ly�-�sr.�� ZIP: 5 5 ��5,6 `a
<br /> = Email and/or Fax
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<br />�� PROJECT INFORMATION:
<br />��
<br />�'E Type of Project: Any earth movement may require
<br />�..
<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 �;i
<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) $ ,�G' L�(,S
<br /> .. -�
<br /> APPLICANT ACKNOWLEDGEMENT: r�
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<br /> • Agrees to provide all information required or requested by the Building Department; 3-:�
<br /> ��:
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<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
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<br />��� but to reject it until it is complete; �n
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<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 />`t confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �:
<br />� ,
<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: ,� � Date: � — 6� �—/�'
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<br />��' Last Updated: 05-04-2009
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