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<br /> ' � � '� City of Orono �
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<br />�k � Building Permit Application for Internal Work �'�
<br />�4 .-
<br /> (windows, doors, siding, re-roof, etc.) �
<br /> ��; Mailing Address: �
<br /> ��' 0 � Permit number: �;
<br /> � �4v ,��\ PO Box 66 �
<br />�,� /Q o\\,1 Crystal Bay, MN 55323-0066 Date received:
<br /> � ��
<br /> :�� // * �� �.'�
<br /> " Received by: �
<br /> ��. � ( ���4�;�
<br /> a � Street Address:
<br /> � '���d� � � 2750 Kelle Parkwa
<br /> Y Y Plan review fee:
<br /> �' �t`�kESH`�% Orono, MN 55356
<br /> Total Fee:
<br /> '� ' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us >
<br /> ��'
<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 /> ✓�.�=3 / -�
<br />�'� Job Site Address: :�7�'.�;C� /7�,�t-! Sl�''� ,�',c3-�- C����u /yjh `�
<br /> t ,, Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br />��' lf yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wil/be
<br />�
<br /> required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed.
<br />� CONTRACTOR/APP ICANT INFORMATIO : , ,.�
<br /> �< �
<br />� Name: �� � ��c� _ c
<br /> State License# �' Expiration Date: ,� j p
<br /> g Phone: � 3�.� - �� office lo/,�,- 7 -- < < cell
<br /> `' Mailing Address: y D " '`' : Cit : �c��h ZIP: '��/
<br />��, Contact Person: �,��- �f,�� S Applicant is: Contractor / Homeowner (Circle One) `�'
<br /> Email and/or Fax: ri �i/if-�-.ur � � ���,,�r�r� ;� j- '�
<br />�� �
<br />�? PROPERTY OWNER INFORMATION:
<br />��: . G� / o��/e �
<br /> �_; Name: � � � �
<br /> s�,;' Phone (daY)� ��.;�3-.71�7 l�o�C.Y� <<
<br /> , Address: o-?l��/� /�a�'� f✓�.� �i'.�1� CitY� �i2��rJ, ZIP� .55..�9
<br />-��;5 Email and/or Fax _
<br />:'.�:;; �
<br /> FV; PROJECT INFORMATION:
<br />�fi;� Type of Project: Any earth movement may require
<br />��� ❑ Door(s) ❑ Remodel MCWD review&permits
<br /> ❑Water Damage
<br /> .; Minnehaha Creek Watershed District(MCWD) ;`
<br /> F,t,� ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> �r: Deephaven, MN 55391 ��
<br />� F`
<br />,� ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590
<br /> .
<br /> Re-roof Fax: 952-471-0682 F
<br />�-t-' , ❑ Fire Damage www.minnehahacreek.orp
<br /> �;: Overall Project Description: y�v � l�s���Q���z�� ��i y��'��,5 .�� �� �������
<br /> �< C i' � � /s . x�
<br /> Est�mated Construction Valuation of Project (excluding land) $ --�f�pD,��j �,�
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<br />,,�:' APPLICANT ACKNOWLEDGEMENT: _
<br />��'� • Agrees to provide all information required or requested by the Building Department;
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<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 the information, the a lication ma not be issued.
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<br />�;�: ApplicanYs Signature: �c�/�,���� � �—„�� Date: d��l�� � �
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<br />� Last Updated: 05-04-2009 �"
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