Laserfiche WebLink
. City of Orono � � ��,�;\�b <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: p���d ''��$�3 <br /> g,�,�. PO Box 66 <br /> O \ O Crystal Bay, MN 55323-0066 Date received: 9 c?c`� J D <br /> a ��'"3" Received by: S <br /> ' 3e�:: �, Street Address: <br /> �'�c, 9" G� 2750 Kelley Parkway Plan review fee: D D ��D88oZ <br /> t`�kEsxo4''� Orono, MN 55356 . L <br /> - Total Fee:� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �d �, ,s <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: ��QC� �-����-{- (�(, <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 City Council approva160 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: <br /> Name: (�'J�� �v�o� {-���� <br /> State License# a�3 as5 5S Expiration Date: .3— �( — �j 1�, <br /> Phone: �{ a— �—� office cell <br /> Mailing Address: ' p Cit : ZIP: S S 3�{S <br /> Contact Person: ,��,� � �Q,�� Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: q��—q�3— lS�� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �i.t�^u � ������ ��-��� <br /> Phone (day): <br /> Address: Z�GC� j�(���,_Sc��L 'p�. City: C�i����z; ZIP: SS 33 � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) �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 ❑ Fire Damage www.minnehahacreek.orq �. <br /> Overall Project Description:�,�,;�c t � �:,�k� {��,�(., --{�� c� 4 ��c�=�;- �,�� ��,,� �-(-�„e�-1r,.-l-�Yw�� � <br /> Estimated Construction Valuation of Project(excluding land) $ S�,�x�-� ��u� ¢I �"� i`�`�-`"' ";, <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 I the informa 'on,the a lication ma not be issued. <br /> �Applicant's Signature: ��.� Date: 9—���d <br /> ��'" �`J/�z`� <br /> Last Updated: 05-04-2009 � <br /> � <br />