HomeMy WebLinkAbout1995-006963 - rr/re-side - part tear-off _
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� P 1rVIIT
CITY OF ORONO PERMIT TYPE:
2750 Kelley Parkway- P.O. Box 66 - - _ _-
, Crystal Bay, Minnesota 55323 Permit Number: _ _
(612) 473-7357 Date Issued: r j -
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SITE ADDRESS:
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DESCRIPTION:
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REMARKS:
FEE SUMMARY:
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' APPLICANT/PERMI EE SIGNATURE ISSUED BY:SIGNATURE
� •
CITY OF ORONO - BIIILDING PERMIT APPLICATION
Total Fee: $
� I, � `� Date Received:
Date Approved :
Entered By: _ �<��� Permit tt: � � `��
AT•T• INFORMATION MIIST BS SIIBMITTED IN FIILL BEFORE PLAN RE�7IEW WILL Bg STARTED
(See Check-off List Enclosed)
---------------------------
TgE APPLICANT IS: (circle one) OLdNER or CONTRACTOR
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JOB SITE ADDRBSS: " '
(work) %�� -J�%/
'�� � /��' P � PHONE: (home) ���" �L�'�G
NAME OF OWNER- � r
MATLING ADDRESS: /��SS ���2.��` ���ry �� CITY:� CC%�=-i ZIP: J �
CONTRACTOR: )P I--�- pH���
MAILING ADDRESS: CITY: ZIP:
STATE LICENSE: #
ARCHITECT/ENGINEER: PH���
MAILING ADDRESS: CITY: ZIP:
N�: REGISTRATION n
TYPE OF WORR: New Addition Accessory Structure riove
Demo Remodel/Alteration�_ Renovate Land Alteration
' ` � �' � J C
PROPOSED WORR (describe in detail) : �
;4/L"(/� .'"��C..�' G/"7';
(. (,
STORIES: SQ. FEET OF EACH FLO�R=
NO. OF BEDROOMS: GARAGE STALLS: ATT. DET.
�/ t� i
ESTIMATED CONSTRIICTION VALUATION (excluding Iand) : $ Y �[ � -
I hereby apply for a building permit and I acknowledge that the information
above is complete and accurate; that the work will be in conformance with the
ordinances and codes of the City and with the State Building Code; that I
understand this is not a permit and work is not to start without a permit; and
that the work will be in accordance with the approved plan.
AP
� DATE: S �
APPLICANT'S SIGNAZTURE: �
. �
� OIiONO
CITY of
Post Office Box 66•Crystal Bay, Minnesota 55323•MuniciP� ���
�
� _ � � On the North Shore of Lake Minnetonka
DATA PRIVACY ADVISORY
In accordance with M.S. 13.04, Subd. 2 , "Rights of subjects of
data", we would like to inform you that your request for a permit or
license from the City of Orono or any of its departments may require
you to furnish certain private or confidential information.
You are notified that:
l. The information you furnish will be used to determine your
qualification for the permit or Iicense requested.
2. You may refuse to supply data, but refusal may require that
the City deny the permit or Iicense.
3. The information may be shared with oth�ocesscthe permit or
federal agencies to the extent necessary to p
license.
4. If your requested permit or license requires Council ac��or.
to approve, some information may become public.
5. You have certain rights under M.S. 13.04 to review private
data on yourself.
6 , Your full name is required to process this application or
pe?�mit.
�io��K
�� � � Last
First Middle
p� ^I ( �
� 0 `�� �V� � (,l� )Ci �C_�'x -
Address
,/� � -�
�G� � I ►I� -J��
City State Zip
�-t7i - Iu � �
Phone
I understand my rights as stated above.
'
�____
Signature
BUILDING&ZONING—473-7357 • ADMINISTRATION&FINANCE—473-7358
• PUBLIC WORKS —473-7359
ASSESSIN G