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<br /> . City of Orono �
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<br /> Building Permit Application for Internal Work &
<br /> �
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<br /> (windows, doors, siding, re-roof, etc.) iz
<br /> �-d0�� �.
<br /> �O� MailiPO Bo r66. Permit number: �`
<br /> Crystal Bay, MN 55323-0066 Date received: 1��,�j °�
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<br /> O`�il\�' O I� Received by:
<br /> ,� t� ��:��.� ,, Street Address: �.
<br />€:;: �'.F,t' , ����xp„ Gti� 2750 Kelley Parkway Plan review fee� �
<br />�.� `�gE H�`'� 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: s:
<br />��!
<br /> Job Site Address: " �((� � (, 2 i L q-U�,
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o �
<br />;,, If yes, a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuftle bus servrce will be a`
<br />'��' required unless applicanf demonstrates sufficient on-site parking is available. Non-permitted events will nof be allowed. t`
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<br />� CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: K19V�,•�c.��D �oF�,,,l� �;�
<br /> �' State License# "Zv�O3oyy� Expiration Date: � 3� �o� o �
<br /> �= Phone: 7�3 -- �(r�y- 2��y (office) "?�� �g7-c �� � (cell) '�
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<br />�,'; Mailing Address: 3 ��t � i ��-� �rt n��w Cit� ,q„��v_,� ZIP: sj� �� �
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<br /> � Contact Person: J�>�.� /t.tr,y��L,�r Applicant is: ontrac'tor / Homeowner (CircleOne) �
<br />�: Email and/or Fax: ;;�
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<br />`� PROPERTY OWNER INFORMATION: �
<br /> ,� �
<br />� ' Name: QA,ti.qL� �osg �
<br />� ` Phone (day): �r5z -�t'll- ��On�
<br /> �' Address: �u�,�, L�'2, c... �,q.viL City: IN,p�'Z4'i�'� ZIP: SJ ��/
<br />�,,.
<br /> Email and/or Fax
<br /> F�� PROJECT INFORMATION:
<br />�'� Type of Project: Any earth movement may require '�`
<br /> � MCWD review&permits -�'
<br />"'� ❑ Door(s) ❑ Remodel ❑Water Damage
<br />�'- Minnehaha Creek Watershed District(MCWD) ��'.
<br />�k ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd '
<br /> Dee haven, MN 55391 �'
<br />�,. p �s�
<br /> ❑ Si ing ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 �
<br />� : Fax: 952-471-0682 ��
<br /> s ,�; Re-roof ❑ Fire Damage www.minnehahacreek.orq �'
<br />�"` Overall Project Description:�� �(=
<br /> �� Estimated Construction Valuation of Project(excluding land) $ (p3o� �� '"
<br />��
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<br />��; APPLICANT ACKNOWLEDGEMENT:
<br />��.:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> t:,;`
<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 />�';_ • 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 enerall cannot be iven to either the ublic or the sub ect of the data. Our �
<br />�;�, 9 Y 9� P 1 �
<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 />�k ApplicanYs Signature: �- ,� ��:-..,/� Date: (���/3�n�-
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<br />�:, Last Updated: 05-04-2009
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