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<br />�_ . City of Orono `������ - � �
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<br /> , 2.
<br /> ' � Building Permit Application for Internal Work ��
<br /> r� �
<br /> : (windows, doors, siding, re-roof, etc.) �
<br /> �
<br />�'= Mailing Address: , f� �,
<br /> �,i,�,��\ PO Box 66 Permit number. �(��✓�_ ,j� �
<br />#w7:
<br /> 0 k� Q .\ Crystal Bay, MN 55323-0066 Date received: � �l,.�U�1 ��
<br /> � � �e;_;� �� Street Address: Received by: ' �
<br /> a
<br /> = �' '''"� �ti r 2750 Kelley Parkway Plan review fee: �
<br /> � .4 ,.
<br />��3'� �`�gESHo4.� Orono, MN 55356 �
<br /> �
<br />� ' Total Fee: ��p�p,�LJ-J ��'
<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 /> ��
<br />`�°' Incomplete applications will be returned. (Please print) �;
<br />� GENERAL INFORMATION:
<br /> ��
<br />�:: Job Site Address: 1 '? 2 v L `/�r-r.Q.-�- ;/�li �%/Zc?,�- cf ��
<br /> �
<br /> Will this be a Parade of Homes Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No �
<br />�s lf 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 /> �
<br /> CONTRACTOR/APPLICANT INFORMATION: �.�
<br />�.
<br /> Name: /�vvf C�.1,�r��-L-`l /�� Z-�z � .-
<br /> State License# _ �p��7 •z r�-� Expiration Date: 3� :��= 2 0 (b d r
<br /> �� Phone: J���S�c� -G�/<�N/ (office) cell F�
<br />�':� Mailing Address: 1�� l>..�- �i <<-- Cit : ,.vi�r,v�-� ZIP: ����( )
<br />�,; Contact Person: f0 6�1i� '702 • 2 ��- 7 Applicant is: ract / Homeowner (CircleOne)
<br /> Email and/or Fax: 76 S- �;�''7 �%U 9'�
<br />_,, PROPERTY OWNER INFORMATION:
<br />�°� Name: �
<br />€ Phone (day):
<br />�� Address: ��z � ��r�,�� ,/,�G-� �
<br /> Cit : c�Iz�.-z-c� ZIP: ��
<br /> Email and/or Fax `��s
<br /> ��
<br /> ° PROJECT INFORMATION: �
<br />� � T e of Pro'ect: �
<br />�� � YP 1 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 /> ',i Deephaven, MN 55391 �.
<br /> � ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> ;a-
<br /> g Re-roof Fax: 952-471-0682
<br /> ❑ Fire Damage www.minnehahacreek.orq
<br />� Overall Project Description: -
<br />� Estimated Construction Valuation of Project(excluding land) $ �-> "� �1
<br /> Y^ P�
<br /> �.� APPLICANT ACKNOWLEDGEMENT:
<br />` � • Agrees to provide all information required or requested by the Building Department; �
<br /> e ,
<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 a�ternative � �
<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 �ication ma not be issued. �
<br /> ,
<br /> ;- ��._.--''",_ ! �
<br /> ���'J :I'.__. l4�i
<br /> ApplicanYs Signature: ` �j'�� `,��-/�/"�J�f Date: � �6� � � ,�
<br /> :�
<br /> Last Updated: 05-04-2009 k;
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