Laserfiche WebLink
} T <br /> 2 1 S { <br /> City of Orono .r� . <br /> ?�'. .,4 4 -,,,IV41 <br /> , Building Permit Application for Internal Work x . <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address. K 'A <br /> Permit number: <br /> ‘-1 (3.4.01\\ PO Box 66 Crystal Bay, MN 55323-0066 Date received: . W <br /> \\";, <br /> Street Address: Received by: <br /> 1 <br /> ' <br /> il <br /> ��t ,y � Gtiti 2750 Kelley Parkway Plan review fee: <br /> �kESH04`� Orono, MN 55356 <br /> Total Fee: <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: L�-c�`� Soles{-, et:D C _ lR L -6i Aad / �1c- r <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? L Yes , ‘ lo <br /> 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/APPLICANT INFORMATION: I D <br /> Name: y L y mC, LA-71-i\ -7---' 6 6i�1 rt) ,tet-.T-E'I S l 1.,), /t-C <br /> State License# 53-5-g- Expiration Date: 3/3//„2n/o <br /> Phone: 73- 7.3— 3132_-7 (office) <br /> "� l-•(� - 7/g-0?S-7 (cell) <br /> Mailing Address: 1 75 5 ( Lt..tl-t� •1_<,,,,-A D.y City:PL . L ZIP:SS-V}i7 <br /> Contact Person: ID-ft"—E- / Applicant is: �ntractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: j-<+k YNAV - lti ( t' It% <br /> Phone (day): Z. - L-7.7-- .35L , I <br /> Address: tf� 5 �c cry old .S7�k �y l��Qc� City: ;(,1j �ak ZIP: 5 5- 3 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review &permits <br /> ❑ Door(s) E Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: Tr,,...,�r,__Rectc,-E . „_5�. .,ttvc, iCtiecy cifock9(' <br /> Estimated Construction Valuation of Project (excluding land) $ <br /> v� <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 /> required by law. If you refuse to sus sly the information, tJ —d pli : •n ••-y not be issued. <br /> 1 A <br /> Applicant's Signature: - ,, `ti 4 Date: Com—1, a.\, <br /> V� j <br /> Last Updated 05-04-2009 <br />