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<br />�& -� City of Orono �
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<br /> 4�� � Building Permit Application for Internal Work �
<br /> �` (windows, doors, siding, re-roof, etc.) ,�
<br />�� �¢ Mailing Address: �
<br /> '€' �.,0,� PO Box 66 Permit number:
<br />�.
<br />� Crystal Bay, MN 55323-0066 Date received: �
<br />�a�: O �4; O .
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<br /> '��� a �"��•-��'- a, � St�eet Address: Received by: �:;
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<br />�; ��t '' ''� �ti 2750 Kelley Parkway Plan review fee: �
<br /> � 9kESIIOg'� Orono, MN 55356 �
<br /> �
<br />��z" Total Fee:
<br /> � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
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<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 />,�� JobSiteAddress: ��,;; /� �'��='�� �����t �� �.
<br />�x Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No ��
<br />�, lf 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 /> r�� required unless applicant demonstrates sufficient on-site parking is available. Non-permitfed events will not be allowed. a�
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<br />�� CONTRACTOR/APPLICANT INFORMATION: ) �,,
<br />�5,. Name: � '�� �� � �=l -r ��� � 4� ��
<br /> � State License# �;
<br />��_ .,2�t; � y13 �-f � Expiration Date: 3 3 /�> ��
<br /> Phone: '7�,� � t, .- office cell `�
<br />_; Mailing Address: � Cit : � �ti2• U; �: �c �°
<br /> ZIP: ��C� �;
<br />�� Contact Person: a Applicant is: racto� / Homeowner (CircleOne) �
<br />�`� Email and/or Fax: 7� - 7 � �� �
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<br />� �; �
<br />�� PROPERTY OWNER I FORMATION: k�
<br />��� Name: �����.Gi,;.� - .,�� n� ��
<br />�a� Phone (day): � � - c.�- /_ �
<br />�:: Address: (;, `3' - �t '�' Cit : ZIP: °�
<br /> � Email and/or Fax
<br />�;�
<br />��� PROJECT INFORMATION:
<br /> ��
<br />� ��
<br />�� Type of Project: Any earth movement may require
<br /> MCWD review&permits .�
<br />�'-I �Door(s) ❑ Remodel ❑Water Damage �:
<br />��` Minnehaha Creek Watershed District(MCWD) ;�
<br /> ❑Window(s) [�Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br />� � �
<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: � ��- i':; .� ��� �� -,2-� , . ����� ,� � �
<br /> . '" � � lL' ' -�,� 1�� � � _ �
<br /> Y�, _ Estimated Construction Valuation of Proj�ect(excluding I nd) $ D�c� cv �
<br /> � 5�
<br /> ��: APPLICANT ACKNOWLEDGEMENT: �
<br /> • Agrees to provide all information required or requested by the Building Department; �
<br /> �
<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 /> t i• but to reject it until it is complete;
<br />�.�,
<br />��t:
<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 F�
<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 G�
<br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. =a
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<br /> ;��
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<br />�,: ApplicanYs Signature: 'G�'��� Date: � � /L�-
<br /> . �
<br /> F�;;, Last Updated: 05-04-2009 � �
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