|
� -�'c ' "� g� t , ti ��� �
<br /> ' d i� �.� '� � .�� S..
<br /> S r •f� d
<br /> ' . . . � . i . .�&�ss .. �� �``���.
<br /> g�= City of Orono �
<br /> ra� Building Permit Application for Internal Work �
<br /> �::
<br /> � (v�rindows, doors, siding, re-roof, etc.) ��
<br /> 4. �'
<br /> ; Mailrng Address: Permit number: 0����—d b
<br /> r.
<br /> �v�,� PO Box 66 /�/
<br /> Q .:\ Q Crystal Bay, MN 55323-0066 Date received: ! /�
<br /> ' }��.�
<br /> ,a � ��� s, Street Address: Received by:
<br /> �'.� ° 9'��� �ti�' 2750 Kelley Parkway 4- � Plan review fee: //
<br /> t�'kESH�g'� Orono, MN 55356 U/ .'
<br /> Total Fee: S� � 3���
<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) r �
<br /> " GENERAL INFORMATION:
<br />�: Job Site Address: ��Z' /L� /�/1�� f��(�E ��10�/�� �S �� �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes .� No
<br /> If yes, a special evenf permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be y'J
<br /> " required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> i�,.:
<br /> ��
<br />� ; CONTRACTOR/APPLICANT INFORMATION:
<br />, _,
<br />� Name: �U,4�c�S C/?�"--�.,cJG �•L�G.
<br />� ; State License# Z�� -� �� �� Expiration Date: 3/�� �
<br />'�� Phone: '�'
<br />�; ��2.- �zs- �iv/ (office) lo �L�z>Z - z�� (ce1�)
<br />�fiK Mailing Address: � ,� c,�,+e��o = Cit : = ,�� � ZIP:�`�
<br /> Contact Person: _ � _ Applicant is: Contractor / Homeowner (Circle One)
<br /> 5�£� Email and/or Fax: 5si-yZ,Z�-p r.f g Z
<br />��_�
<br />�.
<br />�� PROPERTY OWNER INFORMATION:
<br />��;
<br />��. N a m e: �2�%��2,4�D.�c%0,4 ,�/�,�Jc�c.� �
<br />�'�'� Phone (day): �; �°/2,�G� - �/�'S c
<br /> Address: q�'a ✓U� -4��j �/2�[i� City: �i2v,Giv ZIP: �""5 � �� �
<br /> Email and/or Fax ;�:;;
<br /> �
<br /> ' 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 />�;'� ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ��
<br />�'' Deephaven, MN 55391
<br /> r;-; ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br />�p Fax: 952-471-0682
<br /> ` �Re-roof ❑ Fire Damage www.minnehahacreek.orq ��
<br />�" Overall Project Description: �
<br />�
<br /> _ Estimated Construction Valuation of Project (excluding land) $ Z �O�� p v `�
<br />,�,,
<br /> �t� APPLICANT ACKNOWLEDGEMENT:
<br /> ��
<br /> �i �� 4 • Agrees to provide all information required or requested by the Building Department; �
<br /> 4�
<br />�- • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they .
<br />�ti: are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
<br />�e, but to reject it until it is complete; �
<br /> �.r.
<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 �r5
<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 /> ��,�
<br />��u: re uired b law. If ou refuse to su I the information, the a lication ma not be issued.
<br />�"'
<br /> �;�
<br />�- ApplicanYs Signature: /�j�,�_ ��-�� Date: y-/�j -- /�
<br />�
<br />,,:,,
<br />�„ Last Updated: 05-04-2009 �
<br /> , � a
<br /> � � . s �� � "?6°'a . 3°"A`A # �"'c&^`^ ,�'x"` t�
<br /> �r.,n ��a);
<br /> , ... . .>..e.w�. ,.�.�.i..S��- .._ .c. �1< ...,...n.z ���� ..�se�.v_ ..2�'9<.�'%1�'InY�..w:a..n ru�:t�e�i�'.3k��� . �._...�•__��
<br />
|