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, City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permitnumber: �0��—�OSb <br /> O.¢,�,�.0 PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: .2'3"�� <br /> a �,, StreetAddress: Received by: �C-'*' <br /> ti 2750 Kelley Parkway Plan review fee: �O O— � <br /> G <br /> lqxEB�a�*d Orono,MN 55356 ;� 5/ ��aj/ d <br /> {J� al Fee: r� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �� 7��(�.' 7�j <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: � ;� ��y�� �� S S J l � <br /> Job Site Address: 1�� <br /> Will this be a Parade of Homes, Remodelers Show se Home or other Display Home? Yes No <br /> If yes,a special event permit is required with Police Department and City Counci!approva!60 days prior to the event. Shuttle bus servi il e <br /> required unless applicant demonst2tes su�cient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICA�INFOR ATI N:CDI,(�N��-��n vS <br /> Name: ir� /�t� <br /> State License# Expiration Date: <br /> Maii ng Address: office Cit~: ZIP: �fl /Z ��d��s� <br /> Contact Person: S Applic nt is: Contractor / Homeowner �c���a,a� <br /> Email and/or Fax: C S� b . <br /> PROPERTY OWNER INFORMATION: �������v '3 5 g0 �'�� <br /> Name: SQ�'Y1�. ,$ �l V <br /> Phone(day): <br /> Address: City: ZI P: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑Door(s) emodel ❑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) S �"j�,bO a <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Departrnent; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they i <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 infortnation that you are asked to provide on this application is classified by State law as either pr'Nate 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 eRher 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 govemmental agencies <br /> r uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: a��/b <br /> Last Updated: 05-04-2009 <br /> . <br />