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� Jun-O7-2010 10:45am From-CITY OF ORONO +9522494616 T-289 P.001/001 F-192 , � `rv��l�� - Ci of Orono �! � � �� Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Malling Address: Permit nur(tber. � —�d� 0.�,O,�O PO Sox ss . • Crystal eay,MN 55323-0066 pate recelved: D� � � Street Addreas: Received by: ' 2750 Ketley Parkway Plan review fee: �.��,�� Orono,MN 55356 `- 7otsl Fee: �(�C'�"Q� Main: 952-249-4600 Fax: 952-249-4616 www.oi.orono,mn,us i This application form must be completed in full and all required information must be submitted. Incomplete applications will be retumed. (Please print) GENERAL INFORMATION: ` ' Job Site Address: j��F��5� j�j/�T Will this be a Parade of Homes, Remodelers Showcase H4me or other Display Home? Yes No lfyes,a spacial evenr permit is required wifh Polke Department and Ciry Councll approva!60 deys pdor to the ewnt. ShutNe bas service will be required unlass app/icant demonstrates sufficianf on�site parkin9 is eveilaDle. Non•permittetl events will nof ba afbwed. CpNTRACTOR I APPUCA INF R ATIO : Name: State License# Expiration Date: _,fj /d Phane: � � office „ �-��T cell Mailing Address: C' .� P:,�-r/y� Contact Person: Applicant is: Contractpr / Nomeowner �co-�.o�.� Email and/or Fax: , �-• a--� PROPERTY OWN F A O : Name- / Phone(day): — Address: ,? Ci : �/r ZIP: �� Email and/or Fax PROJECT INFORMATION: Type of Projod_ Any earth movement may require MCWD r�view&permit8 0 Door(s) C]Remodel C]Water Damage � Minnehaha Creek Watershed Dis�rict(MCWD) ❑Window(s) ❑Repair []Storm Damage 18202 Minnetonka BNd Desphaven,MN 55391 ❑Siding ❑Restoration ❑Other:(specify) Phone: 952-471-0590 Fax: ��52-471-0682 ❑ Re-raof ❑Pire pamage .min��ehahacreek.o�a Overall Project Description: � � Estimated Construction Valuation of Pro"ect excludin land) � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all informaGon required or requested by lhe Building Department; • Certlfies that the infarmation supplied is true and correct to the best of his/her knowledge. The�ppllCant recognizes fhat they are solely responslble for submitting a complete applicadon being aware that upon failure to do yo,the stsff has no aftema6ve but to reject it until k Is complete; • Some or all of the information that you are asked to p�ovide on this applicatlon is dsssified by State law as efther private or confidential. Private data is information which generally c2nnot be glven to Ihe public but csn be givgn to the subject of the data. Confidencial data is information which enerally cannot be given to either the public or the subject of the data. Our purpose and intended use of this informatio is to annually update • cords and records of other gov�mmental agencies r uired b law. ►f ou rafusa to Su I d�e i rmadon, e a II o a not be issued. Applicant's Signature: ..�• Date: � Last Updatod: 05-04-2�09