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City of Orono <br /> - � Building Permit Application for Internal Work � <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �j,�,�. PO Box 66 <br /> �� � <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ,� ����-�� �, StreetAddress: Received by: <br /> �u��> <br /> �'.�, �'°� '�� �ti 2750 Kelley Parkway Plan review fee: <br /> �`�kEsxo4''� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <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: �.(��'� \ � <br /> ; �:e,.�YY1 �-�_ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> !f 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 /> required unless applicant demonstrates sufficrent on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: � J <br /> Name: �i��G�.�.(��-� ��.�vl G✓5 /�� - <br /> State License# �v�; :3� g� '7 Expiration Date: ;3 � /f <br /> Phone: jo - - d' oL office cell <br /> Mailing Address: (�� � ' � � Cit � .-�v� ZIP: , 3 � <br /> Contact Person: �oy,�,.�c_� Applicant is: -% Homeowner (Circle One) <br /> Email and/or Fax: �y(o3- -�!/b - -7,p�(� <br /> PROPERTY OWNER INFORMATION: � <br /> Name: �/�:-rc �7 �t,��o�. ���-,.:��CG✓ <br /> Phone (day): �;:� . , _ U ' <br /> Address ��L�:2� `���_,-� C:.:� - City: �;v��� zIP: 4,355'� <br /> Email andbr Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�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: •G;�;� v ' - Yk`�==� � S <br /> Estimated Construction Valuation of Pro ect(exc uding land) $ 3i, ���} . .= <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 t inf�rmation, the a lication ma not be issued. <br /> A IicanYs Si nature: '� �� � �"�1/ �G/� � <br /> pp g � � ,:ti Date: <br /> Last Updated: 05-04-2009 � <br />