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<br />;, � City of Orono �
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<br />��`- � Building Permit Appiication for Internal Work �
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<br />�_% (windows, doors, siding, re-roof, etc.) �
<br />�` Mailing Address: Permit number: ��
<br />�� ��,� PO Box 66 �
<br /> w�` � O Crystal Bay, MN 55323-0066 Date received: �
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<br />�': a �'�'�e.,^� � StreetAddress: Received by: �
<br />�z' "� 2� a,�;'r �4 �
<br />� h � � �� 2750 Kelley Parkway Plan review fee:
<br />��� ��kESHo4'� Ornno, MN 55356 �
<br />_� Total Fee: �
<br />�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �
<br />�r� This application form must be completed in full and all required information must be submitted. �
<br /> �.
<br />°" Incomplete applications will be returned. (Please print) ��
<br />�` "�
<br />`�. GENERAL INFORMATION: �
<br /> Job Site Address: ' -7 / /� �� J k
<br />�w`, ;'�j^ / �� hCric� G�4/1i F>�`C�1
<br /> ,�`; Will this be a Parade of Homes, Remodelers'"�howcase Home or other Display Home? ❑ Yes ❑ No ��
<br />"�= If yes, a special event permit is required with Police Departmenf and City Council approval 60 days prior to the event. Shuttle bus service will be
<br />��ire uired unless a licant demonstrates sufficient on-site arkin is available. Non- ermitted events will not be allowed. £�
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<br />��� CONTRACTOR/APP ANT INFORMATION: �
<br /> � Name: 1���5�����,�� ��..�<<-�Ir J�v« a��� l.=�f�.•,�,3 LL� �
<br />�,� State License# ,��3���,/ Expiration Date: ����. //
<br /> N� Phone: Li�: �c�� G�.,i (office) (cell)
<br />� Mailing Address: ; 73���/ r"c,.��, 5-t _-v�> City: % �%-^�Y 7 ZIP: :tr��
<br />��' Contact Person: �,kE ��:i,►�zez:-
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<br />�� Applicant is: ntrac / Homeowner (Circle One)
<br />�, Email and/or Fax: �✓'� Icl<IISc�;3r.� « ��c�.�c�d5t,.���. r
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<br /> PROPERTY OWNER INFORMATION: �
<br /> �'M°'1 Name: ���:7 �I �K �`a,
<br /> � Phone (day): �%�-� y"�3 (-;�9��
<br />� � Address: _ �S�S" L-vr,�, L�k,� (�l�c� City: %/Z�,�,��- ZIP: '
<br />�'��: Email and/or Fax '' �
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<br /> ' PROJECT INFORMATION: ��
<br /> �'�� T e of Pro'ect: �
<br /> Yp J Any earth movement may require k..
<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 /> �;
<br /> � Deephaven, MN 55391
<br />� ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590 �
<br />^� Re-roof Fax: 952-471-0682 g�
<br /> ❑ Fire Damage www.minnehahacreek.orq
<br />�� ;:
<br />�� Overall Project Description: D`� ,2,��F C ��- �
<br />�,; �
<br />�A: Estimated Construction Valuation of Project (excluding land) $ /5��p�. �
<br />�: �'
<br />�,:� APPLICANT ACKNOWLEDGEMENT: �
<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 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 />� �
<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 z
<br /> �.
<br /> �; data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our �
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<br />�f�� 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 the infor tion, the a lication ma not be issued. ;;:�,
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<br /> ApplicanYs Signature: '� Date: �" `��- �"' %C�
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<br /> Last Updated: 05-04-2009 �
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