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r . C i ty ofi O ro n o `� .� j 3�-7 S�
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: �(,�0 6
<br /> //��,0,�.�\ PO Box 66 Permit number:
<br /> i;� . O�\ Crystal Bay, MN 55323-0066 Date received: � (S js
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<br /> '�St �,j,� StreetAddress: Received by: d �
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<br /> �',�, � �'.�, �ti�'� 2750 Kelley Parkway Plan review fee:
<br /> �qkESIIOg'%/ Orono, MN 55356
<br /> i , /
<br /> ��---"" Total Fee: p� 5�3' c��
<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 /> Job Site Address: � �(W S jli'�,��-t-�r�:�,z �2����
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> If yes, a special event permit is required with Police Department and Crty Counci!approval 60 days prior fo the event. Shuttle bus servic will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APP,I�ICANT INFORMATION: �
<br /> Name: IS _j��r.: L. �.�-�:�.a r-E�, . ,12.
<br /> State License# Expiration Date:
<br /> Phone: (office) (cell)
<br /> Mailing Address: City: ZIP:
<br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORM TION: ( .� �
<br /> Name: ��� . _���rf>.J I-�,�.,_�,w �-�. � 'Z ,
<br /> Phone (day): (s,/� - b� S-- 2� � �
<br /> Address: `� C> . ,;3c,k; �-c� City:C•2 yS.� �•-�y ZIP: S S 3�.� ,
<br /> Email and/or Fax � j � ���;��. rtz, �=, �, S � , c�-�,�-1
<br /> PROJECT INFORMATION: IZ �u��:�.�C %�h�S 1> S ��<=�,�.�z--.�- -- �Z������%� S�,� .,�.� ����:.� .
<br /> Type of Project: Any earth movement may require
<br /> " MCWD review&permits
<br /> [�'600r(s) [�emodel ❑Water Damage
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> 0�/indow(s) epair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> �ding �estoration ❑ Other: (specify) Phone: 952-471-0590
<br /> - Fax: 952-471-0682
<br /> �e-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description: ��„��„� � L� ;$;7 �-�,,,,�,�u,�,� — ����,,.,,L,�, S��,,.� ����� .� �
<br /> Estimated Construction Valuation of Project(excludin land) $ / �S1 �'' c��
<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 to su e-i�formation..the a lication ma not be issued.
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<br /> ApplicanYs Signature: — � Date: l U �1 /U
<br /> Last Updated: 05-04-2009
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