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<br /> • ' City of Orono
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<br /> Building Permit Application for Internal Work � � } � ���
<br /> (windows, doors, siding, re-roof, etc.) �'
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<br /> Mailing Address: Permit number: /O � �D�a- i•
<br /> �.,�,� PO Box 66 ;�;.
<br /> ' 0 Q Crystal Bay, MN 55323-0066 Date received: � 7/ � �
<br /> �.� �� �
<br /> ��'���;, �, StreetAddress: Received by: �
<br /> � ��� �'� �ti 2750 Kelley Parkway Plan review fee:
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<br /> `�kESKog�� Orono, MN 55356 �
<br /> � Total Fee: �g, �5 `�
<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: ��,'��j N�� ' ���" y � �
<br />��. Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No
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<br /> F r If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be "�
<br />� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br />�� CONTRACTOR/APPLI AN �fNFQ$MATION:
<br />�.; Name: �it/l�� /vrn,2n/' '��
<br />� State License# Expiration Date:
<br />�„i Phone: ��S-T�. y�Z j/ (office) (cell) �
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<br /> �. Mailing Address: �� NCll�c-� S �� j�. Cit � ZIP� t�
<br /> Contact Person: �
<br /> ; fiv�'�l Applicant is: Contractor / Homeowner (Circle One) �
<br />��` Email and/or Fax: a
<br />��: ��
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<br />�,,� PROPERTY OWNER WFORM. T1�N: �
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<br />��.y Name: (/V i �rt�Q,v�
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<br />�� Phone (day): 5- - 5��� �
<br /> �,,, Address: �jG;�� �vc��,,, S�-o�,� Cit : ,�i�.. p ZIP: S��j�e� �
<br />�;; Email and/or Fax t
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<br /> �� PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
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<br /> ❑ Door(s) ❑ Remodel MCWD review 8�permits
<br /> ❑Water Damage
<br /> ' ❑Window(s) ❑ Re air Minnehaha Creek Watershed District(MCWD)
<br /> t��, p ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ` Deephaven, MN 55391
<br />"k" �Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590
<br />�.�,
<br />�: Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ �
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<br /> APPLICANT ACKNOWLEDGEMENT: �;
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<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 genera�cannot be given to the public but can be given to the subject of the �
<br />�� data. Confidential data is information which gene�e y annot be given to either the public or the subject of the data. Our �
<br /> purpose and intended use of thi,s informatign,js-'fo annvally update our records and records of other governmental agencies
<br />��; re uired b law. If ou refuse to�su I the'` ormation,the a lication ma not be issued.
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<br /> �fr ApplicanYs Signature: � \ ?i-�"" Date: _� - 2 � ' �v �
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<br /> „ LastUpdated: 05-04-2009 �
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