|
, �" - "�^�„�� � €� k-ar =��� N.�. _ �^v� dr .
<br /> � �'�t++�,� S' ey '=�� � �7' :� t'.
<br />: i_ . .. ,�`y 4 _ ,� _ ,. �5.ry 4 ) su�,.
<br /> � 1��� ,f
<br />�` � S�-� � x: N� t! ,,.2�.��C�'A,A..r��f' S�
<br />:`� � . City of Orono �
<br /> �
<br />}�. Building Permit Application for Internal Work �
<br /> r � (windows, doors, siding, re-roof, etc.)
<br /> R Mailing Address: , _ �. �'
<br /> � g,0,� PO Box 66 Permit number: .�C'/� L�'. > k
<br />�,�! 0 ^1 Crystal Bay, MN 55323-0066 Date received: � -�� /C� �
<br /> I
<br /> \ � $�
<br />,�i� I' �t�' Received by:
<br /> �a � ��a�a� �. Street Address: �
<br /> �'.�, ' � �" Gti 2750 Kelley Parkway Plan review fee: � '
<br /> '�� � g� Orono, MN 55356 �:�
<br /> kEsxo J
<br /> Total Fee: � :� � �O �
<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 />` fi Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: � /
<br /> Job Site Address: `7 � ���� �� 2- �-1 �� �� � �'
<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 Po/ice Department and City Council approval 60 days prior to the event Shuttle bus service wi/l be
<br />;�� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> i; CONTRACTOR/APPLICANT INFORMA�rION:
<br /> Name: � F, `1 /l� � T'� �--�I�� �
<br />��.;; State License# ��� � Expiration Date: 1 d�-� zQ 1 � �
<br /> ; Phone: office cell �'
<br /> j Mailing Address: ��-g -- 5:, �h� ,�, � �..-f�- � � tr . � Cit : d�, ' ,� ZIP:rf � �
<br /> , (' Contact Person: �3���� Applicant is: Contractor / Homeowner (Circle O � �
<br /> ; Email and/or Fax: �.;n ►�.,rz..C,-�.��S';.�r�i'i•,� r�, � �� �� G-> ,,v�
<br />� { PROPERTY OWNE INFORMATION:
<br /> Name: - �'J �l 01- l� S �`�i.�- �
<br /> �'\
<br /> �;;:j Phone (day):
<br />*`�� Address: ) � � Q�Z�,� C�,�c.L-e__ City: ZIP:
<br />"�`j Email and/or Fax
<br /> k'
<br /> rti:I
<br /> ;$3
<br /> � �
<br />`:; i PROJECT INFORMATION:
<br /> r; j Type of Project: Any earth movement may require
<br /> IMCWD review&permits
<br /> � ❑ Door(s) ❑ Remodel ❑Water Damage
<br /> y Minnehaha Creek Watershed District(MCWD) �,
<br />�,-"� ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd 1:.��
<br /> � Deephaven, MN 55391 Y
<br />��' ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 �
<br /> f Fax: 952-471-0682 `;�
<br />�s� ❑ Fire Damage www.minnehahacreek.orq r.
<br />,� Re-roof �
<br /> r��
<br /> �'' Overall Project Description:
<br /> J ��
<br /> Estimated Construction Valuation of Project(excluding land) $ � �� � � � S.�
<br /> APPLICANT ACKNOWLEDGEMENT: �
<br /> • 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 /> • 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 o su t information,the a lication ma not be issued.
<br /> ��
<br /> �;�'
<br /> ��;
<br /> Applicant's Signature: Date: �� � � 2`' I �
<br /> Last Updated: 05-04-2009
<br /> s i^ .�� ,. ; ' } � �,�� .�� �,
<br /> � � �
<br /> .e . _ x .. � �„�.., .. _._. � �.<„__f�' � ._� .���7�.�:��r_„�a��f,?,a;:.z�„_,�,
<br />
|