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. _ City of Orono �- �
<br /> * . -• (��� :1�
<br /> Building Permit Application for Internal Wor�C �C�y
<br /> (windows, doors, siding, re-roof, etc.)
<br /> –<_� Mailing Address: Permit number: �b l�- ll��C 7
<br /> �/�,�,�. PO Box 66
<br /> � Crystal Bay, MN 55323-0066 Date received: b/ O�j 2b//
<br /> i� :h
<br /> �� Received by:
<br /> a j r��, �, StreetAddress:
<br /> �'.�, .'� ,�,,��� Gti 2750 Kelley Parkway Plan review fee:
<br /> L`�g�splHog.� Orono, MN 55356
<br /> �- � `� 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 /> ,„ �^._
<br /> Job Site Address: C� (��:-�fG� J�,�� L%;' C�! ;�vn�; �� -�`> <j�
<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 approva160 days prior to the event. Shutt/e bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil!not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: t�.\��-�e. ��;�.k - V�c..� 't�Cv✓►�� �C'.c�v�o<,a�C.n.c,
<br /> State License# Z_�C� 3 � 3 c�(� Expiration Date:
<br /> Phone: , �,'�Z -.a�;� � 2�7 (office) 5���, (cell)
<br /> Mailing Address: ,� - � ' � � � L � Ci : �:��,��:�er� ZIP: ,1,{,
<br /> Contact Person: �/� Applicant is: o tractor , / Homeowner (Cirele One)
<br /> Email and/or Fax: + a� -" ������
<br /> ,���.--�� '��k ren�-v�-1�_�.� . c��
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: C��;l!e� �- �P��- ��f'�r�c�.-,
<br /> Phone(day): � r 2 - �(L�7- I$v 5
<br /> Address: �yv !Jv�-}d„ /�r�, �47� City: ��ano ZIP: S��"s�,y
<br /> Email and/or Fax L�.�;-t-n,,�,�,� 2'�/U � �c, ! . Co,n,�
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&pertnits
<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 Q Other: (specify) Phone: 952-471-0590
<br /> ,,—, Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage E`71����� www.minnehahacreek.orq
<br /> Overatl Project Description• ��mw•-t re.�+.�,��{ Mc(�� �1�:�.� w�dowg w, � � �
<br /> Estimated Construction Valuation of Project(excluding land) $ ( 2, Ua� �j. _ `
<br /> —��.�_�
<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 Gassified 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� formation,t a lication ma not be issued.
<br /> � ,
<br /> Applicant's Signature: Date: r 2( -�vl��
<br /> Last Updated: 05-04-2009
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