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. � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> g,�,�. PO Box 66 <br /> �, � <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a, �� � �, SfreetAddress: <br /> Received by: <br /> �',�, z ����� ��`�' 2750 Kelley Parkway Plan review fee: <br /> l9gE$Hog�' 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: ,� j /7, <br /> Job Site Address: �p � '' =��'�s <br /> Will this be a Parade of Homes, Remodele Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICA T INFORMATlON: <br /> Name: j/�� ;,� <br /> State License# ����s/c-�'y' ' Expiration Date: 3 <br /> Phone: � - office �- �i;s' �' ""'``' �� cell <br /> Mailing Address: / " -�`� J ' Ci : �' :, Zlp: .�"`r';�'" <br /> Contact Person: -. ,- � Applicant is: Cont ct / omeowner (Circle One) <br /> Email and/or Fax: " ��'? � �., - <br /> PROPERTY OWNER INF RMATION: <br /> Name: �� ���,�,,� <br /> Phone da --�� - �'�y ' � <br /> ( Y)� ���-� i� % c� � <br /> Add�ess: / � �c.dt.t',/nr�a� City:/�+ �a.. ZIP: �"S_� ��� <br /> Email and/or Fax ' <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&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: � , <br /> Estimated Construction Valuation of Project(excluding land) $ ��`ry �`� <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 the information,the a lication ma not be issued. <br /> ���' <br /> �� i:�. � <br /> ApplicanYs Signature: d` Date: / �' <br /> / 1 <br /> T— � <br /> Last Updated: 05-04-2009 <br />