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�^,�^ �-� s �+ r s s � �, ;t � #' � � ��,�'t� �, .. x . ��t p��,�� City of Orono f�A �� X �" t� � � Building Permit Application for Internal Work ,� (windows, doors, siding, re-roof, etc.) T Mailing Address: � 4v�,� PO Box 66 Permit number: Q , Q Crystal Bay, MN 55323-0066 Date received: �'� 1 '��3,�, : � ��'�? �-.��, a � Street Address: Received by: ; �'� °� ��' 2750 Kelley Parkway Plan review fee: � t`�kEsxo4`'� Orono, MN 55356 � Total Fee: � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � �,;,'` ,, This application form must be completed in full and all required information must be submitted. � Incomplete applications will be returned. (Please print) GENERAL INFORMATION: � Job Site Address: �) .� p�,,� � �C� � � Will this be a Parade of Homes, Remodelers Sho case 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 service w 1 be � required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ;�° CONTRACTOR/APPLICANT INFORMATION: y Name: �irl,c��.�_ �'�?Q�`�'Z�.Q-�3 �-�L ,�: State License# o d 3 � Z f �� Expiration Date: / Phone: _ - office - )- `f 7 7 cell `-� , Mailing Address: ,.� )v Cit : .� p ZIP: �� �` Contact Person: � ) Applicant is: Contractor / Homeowner (Circle One) � _ Email and/or Fax: y� --�7d--/?�� PROPERTY OWNER INFORMATION:� � � � Name: J �� p� �' �:. Phone (day): - � Address: Cit : ZIP� '�� Email and/or Fax :� `< r��N PROJECT INFORMATION: �'$ �� Type of Project: Any earth movement may require �'� j A� MCWD review& permits =� ❑ Door(s) ❑ Remodel ❑Water Damage � .� Minnehaha Creek Watershed District(MCWD) � ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ' Deephaven, MN 55391 � �; ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 �� Re-roof Fax: 952-471-0682 � ❑ Fire Damage www.minnehahacreek.orq , �� ��' verall Project Description: y� Estimated Construction Valuation of Project(excluding land) $ ��d - ;�� =:,� APPLICANT ACKNOWLEDGEMENT: �_ • Agrees to provide all information required or requested by the Building Department; �`, 3 • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant 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 information that you are asked to provide on this application is classified by State law as either private or ,� confidential. Private data is information which ge erally cannot be given to the public but can be given to the subject of the �' �� data. Confidential data is information which ge rally cannot be given to either the public or the subject of the data. Our � purpose and intended use of this inf rmation is annually up e our records and records of other governmental agencies re uired b law. If ou refuse to su I the infor tion, the a � tion ma n be issued. ApplicanYs Signature: Date: �/�� <;'. -� � M1.. � Last Updated: 05-04-2009 4 � V f� � ,•r: _ � . S¢ a __3t_,.._ t' _ � ,.�.�..:..�,�_, .� � .