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<br /> -�- , . City of Orono
<br /> ' Building Permit Application for Internal Work
<br />= (windows, doors, siding, re-roof, etc.)
<br />�
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<br />; ' Mailing Address: Permit number:
<br /> �,L,�,� PO Box 66
<br />�� � 0`� � Crystal Bay, MN 55323-0066 Date received:
<br />�� � ���
<br /> � �il a � ��`4,���;� �. � Street Address: Received by:
<br /> � _.
<br />� �� � F"' �ti 2750 Kelley Parkway Plan review fee:
<br />�" � �`�kEsxot''� Orono, MN 55356
<br /> Total Fee:
<br />�"` Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> 4_�; ,
<br />� This application form must be completed in full and all required information must be submitted. s
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br />� � Job Site Address: I j S 1 ����nTt� ,�i-,�r� ��� �'�
<br />�R Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> � If yes, a special event permif is required with Police Department and City Council approval 60 days prior fo the event. Shuttle bus service ill be
<br /> k- required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />��=, CONTRACTOR/APPLICANT FORMATION:
<br /> Name: ��'Tj ��U�;
<br /> " State License# Expiration Date:
<br />�'�; Phone: " (� -0 �� office cell
<br />`'' Mailin Address: <r � �
<br /> p�- 9 �U . -Iv;,v� (L_ Cit : ,�� ��c. ZIP: S"'( ,`;
<br /> 6- Contact Person: Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax�
<br /> PROPERTY OWNER INFORMATION: y-
<br />��` Name: I'�1� �;�-N'V'f
<br />� Phone (day): - -��� —
<br />���' Address: ��1�_ �2 � ,, ��� �i
<br /> i IS1 ,�- ��� City' �,�j�-� �J�� ZIP� �� ,�� �
<br /> Email and/or Fax
<br />�g',
<br />^„;.; PROJECT INFORMATION:
<br />� �` Type of Project: Any earth movement may require
<br /> F'
<br /> ' ❑ Door(s) ❑ Remodel MCWD review& permits
<br /> ❑Water Damage
<br />�, Minnehaha Creek Watershed District(MCWD)
<br />�,, ❑ Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd -
<br /> t�,� Deephaven, MN 55391
<br />��, ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br />'�' Fax: 952-471-0682
<br />�' Re-roof ❑ Fire Dama e
<br />, : 9 www.minnehahacreek.orq
<br />�, Overall Project Description: y �Va;> 5�,, _ �,��:� �,,c� � - �� ��c,�t�v�� � � .- �4� ��. _ Lz�d-�
<br />� ; - -
<br />� X Estimated Construction Valuation of Project(excluding land) $�����1 �� � �(��,.,q�Pi- � /abor
<br />��:
<br />€��"i 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 to su I th ' 'on,the a lication ma not be issued.
<br /> s,`F
<br />�'. C� C� �/�'.�;'—/� ,
<br />;�;F.
<br /> Applicant's Signature: Date: �,3 f�
<br />:;.:
<br />`' Last Updated: 05-04-2009
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