Laserfiche WebLink
City of Orono 35 353, ---- <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address. Permit number: o2d09—De g <br /> ‘'; <br /> °41-- <br /> \ Cr Bax 66 /•0 \ Crystal Bay, MN 55323-0066 Date received: �D/bSO? <br /> `"' Received by: _Z-O. <br /> A ` ��%, A, Street Address: <br /> 1, 1�,�ii Gtiti 2750 Kelley Parkway Preview fee: ,.� <br /> 11(61-i 4S Orono, MN 55356 <br /> --------- <br /> Total Fee:. i 5' `- <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 0,e155 FAA-1-v% 5 <br /> This application form must be completed in full and all required information must be submitted. 1✓,iv/av <br /> Incomplete applications will be returne. (Please print) <br /> GENERAL INFORMATION: c,; � �r . —�3 <br /> 56 <br /> Job Site Address: L 000, tJ� <br /> Will this be a Parade of Homes, Remodelers Showcase Hq, e or other Displa Home? n Yes [ No <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 I APPLICANT INFORMATION: <br /> Name: <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 INFO MATION: <br /> Name: KA ir,,e A c3 !\K-e.2_ <br /> Phone (day): (N—e--c2-12 f e (2 '�l criI 5-6o 0 <br /> Address: 6 S 1---P- A.)t. , La- e City: O'`zp-v -e� ZIP: Sc-3 J <br /> Email and/or Fax t (3 j-¢1 - C t `f 7 �d cj t .cow( <br /> PROJECT INFORMATION: �—' <br /> Type of Project: J [UAL �Lk; Any earth movement may require`J naU��� �� g finrfi MCWD review& permits <br /> ❑ Door(s) p(emodel&i tI ll bYl []'Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> )2'Window(s) 2epair ❑ 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 E Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: /Qin ,,,Zn„0,36,2S ) ( 1A4-o Lk.)di—lt:Ct—GQ-01.4v41 <br /> Estimated Construction Valuation of Project(excluding land) $ 775;c0c/ ,,%, )1t7—(piaede.5 <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 I <br /> required by law. If you refuse to s,•.l the inform;on, the a.•lication ma not be issued. <br /> 7/ <br /> "Iiirre - 0Applicant's Signature: Date: C�Q; � <br /> Last Updated: 05-04-2009 <br />