|
�^'. 's`�a}. ,�.a•i�y'§:�"" ,a� *� y � � aa�a .��� rrk-r�y,� m�-{����.
<br />���� .. .. . ... ��4� '{'�� .x3�y�� � r�,. � � � �_ C+t
<br />�� _ #��l�° 4�..�.:�:1 � � i� v��%a4.. `.
<br />�'{ ` ,,�
<br /> . City of Orono
<br />�,� Building Permit Application for Internal Work �
<br />�- (windows, doors, siding, re-roof, etc.) �
<br />'�° � Mailrng Address: �
<br /> �Q�� Permit number:
<br />� ' PO Box 66
<br />�f" �� Crystal Bay, MN 55323-0066 Date received:
<br /> �: � ,� 0 ,
<br /> r �e , ,
<br />�-ak� ��a r � �-�?� s, ,' Street Address: Received by:
<br />�; \ � ' �'�, ��i' 2750 Kelley Parkway Plan review fee: �
<br /> z �; �9k�SHo��� � Orono, MN 55356 �
<br />�.,:�
<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)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: � 3 z s� G�:<.�c�� �i� � ��.��- < <'� �„�-.�;� �_,�,�� � -�, S_S s�S��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> /f 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 /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />;__,-
<br />�'" CONTRACTOR/APPLICANT INFORMATION:
<br /> � Name: /
<br />�' 3c�-:�; �
<br />�`" State License# Expiration Date:
<br />�� Phone: `��Z �-'7 � 9 y �, �, (office) ��� z �-��� S� �y(cell)
<br />�:.:
<br /> Mailing Address �-�,� Cit : _Z1P:
<br /> Contact Person:
<br />�,�' v�-C� ��,.-�`� Applicant is: Contractor / omeow 2� (Circle One)
<br /> Email and/or Fax: �✓,//,�,,.., ,�;., ;/� �2,,,eM��; , c�.-�-�
<br /> a,,:
<br /> �
<br />�;: PROPERTY OWNER INFORMATION:
<br />�;
<br />��; Name: �-'��..,.���
<br /> : Phone (day): - i 2- �� i q � 7 7 9 ���,c
<br />��"� Address: � 5�-S l�.:.✓G v� c� c-r.�c � � Cit j � 3s �
<br />",�; Y �_�t-�� ZIP�
<br /> s, Email and/or Fax �,i/�,Qt,�ty/ � �1�,,,�.,,.�.f .. ��
<br />;:::` �
<br />��,}
<br /> PROJECT INFORMATION:
<br />�' T e of Pro'ect:
<br />: ; YP J I Any earth movement may require
<br />�'.6 ,��
<br />� ' �uoor(s) MCWD review&permits
<br />��� ❑ Remodel ❑Water Damage
<br /> '` Window s Minnehaha Creek Watershed District(MCWD)
<br />�R�; O ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> Sidin Deephaven, MN 55391
<br /> r L�' g ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br />�<'^ Fax: 952-471-0682
<br />�"`'= ❑ Re-roof I
<br /> ��, ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> ° Estimated Construction Valuation of Project(excluding land) $ �(' �� �b�
<br /> �:
<br />�ri:. ��
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> f'; • 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 /> ��
<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.
<br /> �
<br /> ' ApplicanYs Signature: (ti� �__-� ��� _ , � Date: �S _rU•�� �E'�'� .o
<br /> :;t ,
<br /> Last Updated: 05-04-2009
<br />, .
<br /> t � �� �' > y;
<br /> , � �E
<br /> ; F� } .''4 �'io- "'�#�� _s�",��r ..;y �v,g � ),� �;� ,
<br />. x _,.. .G�-,t�,..m.,_.,_.,� ,...�. ..A �.E.�-, 3.�.��� �v.,�:,£k,. x .�i�:�£�e,�',.,�»., .....w.i�.�+.r�,y �._. . `'��.�`
<br />
|