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City of Orono Building Permit Application for internal Work ` (windows, doors, siding, re-roof, etc.) Mai(ing Address: Permit number: O4v�,�0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: 0 ,� 4,, �, Street Address: Received by: �'�n y� �ti� 2750 Kelley Parkway P{an review fee: t9'kEsilOg'� Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This appfication form must be completed in full and ail required information must be submitted. incompfete applications will be returned. (Please print) GENERAL INFORMATION: � � Job Site Address: %'�pC) ��- } a� �l . Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No !f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus serw will be required unless applicant demonstrates sufficient on-site parking rs avaifable. Non-permitted events will not be allowed. CONTRACTOR/�LICAfIT INFORMATIOt�: Name: � �� CC�. �,lc� "�'�.2� State License# �L� j -�L�s 3 Expiration Date: � � Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: 7�3 �� _��y� c (office) (cell) Mai(ing Address: 5"� � v�, ;,,- City: ,� ��( ZIP: - -� Contact Person: � ��-� 7�yU�� -� Applicant is: ontractor - / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATIOf�: Name: L�/i q�t C,v,`/(, c;6=1 � Phone (day): Address: I��Ur: -c`�/ f ��t� l'�' � City: ��,��.�-j (� ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 �Re-roof Phone: 952-471-0590 � ❑ Fire Damage Fax: 952-471-0682 www.minnehahacreek.orq Overall Project Description: Estimated Construction Valuation of Project (excfuding fand) $ „ �� G�U _ � �'"" APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; �; • Certifies that the information suppiied is true and correct to the best of his/her knowledge. The appficant recognizes that they � are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; � • Some or all of the informafion that you are asked to provide on this application is classified by State law as either private or '� confidential. Private data is inform n whi n generally cannot be given to the public but can be given to the subject of the data. Confidential data is infor ion which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of t is informatio is to annual te our records and records of other governmental agencies re uired b faw. If ou refuse o su I the i formation e a ' �ation ma not be issued. Appiicant's Signature: / , Date: �,� `" � � �� Last Updated: 03-01-2011 '� i�