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<br /> ` ` City of Orono , D ���
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<br />� u d ng Permit Application for Internal ork �
<br />- (windows, doors, siding, re-roof, etc.) �.
<br /> ' ' Mailing Address: Permit number. a��-���o
<br /> f ., �v�,� PO Box 66 � ;
<br />' � , 0 C ry s t a l B a y, M N 5 5 3 2 3-0 0 6 6 D a t e r e c e iv e d: � � 0 g
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<br />; _- Received b �
<br /> ���' �:�, s, Street Address: Y�
<br />� , '� ' s , ,;�� � na
<br /> r �'� "� Gti 2750 Kelley Parkway Plan review fee:
<br /> ��kESH 4'� Orono, MN 55356 � � � `'
<br /> Total Fee: / � Y;.
<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, ��� � � 1 ����j�Q ��
<br /> z+ �� Job Site Address: J �L�'2 L �1�/ �1�(.��-�� ���'y2� � ��Y�;��Y� ,��
<br />�_.
<br />�, , Will this be a Parade of Homes, Remodelers Sho ase Home or other Display Home? ❑ Yes No '
<br /> .��
<br /> 4. If yes, a special event permit is required with Police Department and City Council approval 60�lays prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Nor�-permitted events will not be allowed. �
<br />�.' �� CONTRACTOR/APPLICANT INFORMATION: � �� ��������'�C������-Lti�L���'� �`
<br /> Name: � 1����,� l.�C �' ��
<br />�; State License# Expiration D .
<br />�� Phone: office cell
<br /> Mailing Address: Cit : ZIP:
<br />` Contact Person: Applicant is: Contractor / Homeowner (Circle One) �
<br />= Email and/or Fax:
<br />�:
<br />�
<br /> �;
<br />�. PROPERTY OWNER INFORMATION: � �\`� � ^ 1
<br />"� Name: ��+ ��Cl� ��\,�. � U
<br /> �� Phone (day): ���(��-�-' O � ( _ �
<br /> � Address: �F� Cit : ZIP: ��
<br /> Email and/or Fax � " -y ; �->. �
<br /> �
<br /> x� PROJECT INFORMATION: �� �� �'� � 1 � '
<br />` � � - c`�' � .� '
<br /> ��,, �,��;.� ���t :
<br /> s,;� Type of Project: ,'� �,t�. � � ��/ �� Any earth movement may require M
<br />,�" � v `n� ��'� �`� � �'� 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 /> e
<br />� Fax: 952-471-0682 ��
<br />�*�, ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq �
<br /> z;��: Overall Project Description:
<br /> �
<br /> ��; Estimated Construction Valuation of Project(excluding land) $ ' � � �
<br />�` APPLICANT ACKNOWLEDGEMENT: , . �� ��`�-`'� � ��
<br />�.:
<br /> � i j�� J: �
<br />� � • Agrees to provide all information required or requested by the Building Department;
<br /> ' '�IY�E S�-1,�� c=ALt�,.�,,,
<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 /> ;�.;, ,�
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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 />��'i confidential. Private data is information which enerall cannot be iven to the ublic but can be iven to the sub ect of the
<br />� 9 Y 9 P 9� 1
<br />� 1 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 govemmental agencies �
<br /> �-� re uired b law. If ou refuse to su I the information,the a lication ma not issued.
<br /> ,i ' ,� 1 '�'� ^> �
<br />�� , Applicant's Signature: ��'� �� Date: �� `-')�) `�� � �'
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<br /> -' Last Updated: 05-04-2009 ''� ��
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