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City of Orono `� <br /> Buildin Permit A lication for Internal Work ��� <br /> 9 pp <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailrng Address.� �G/�/ ,� ��L c� _ <br /> �v�,�. PO Box 66 <br /> Permit number: <br /> 0 Q Crystal Bay, MN 55323-0066 Date received: � �,Z.D �U�� <br /> �`�� Received b <br /> � ,�4�'.^,> a. Street Address: y� <br /> ' ���� � 2750 Kelle Parkwa <br /> �'��s�g�� Orono, MN 55356 � Plan review fee: <br /> kEsxo ,�� 9 <br /> Total Fee: �, 7� <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 /> Inc�plete�gications will be returned. (Please print) `��— <br /> GENERAL INFORMATION: �j , S3�.)l,�-J <br /> Job Site Address: � � �,.> � ��, �``� <br /> Will this be a Parade of Homes, emod lers Showcase ome or other Display Home? ❑ Yes No <br /> If yes, a special event permit is required with Po/ice Department and City Counci/approval 60 days prior to the event. Shuttle bus service wil/be <br /> required unless applicant demonstrafes sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: Cit : ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF R TION: � ^ n <br /> Name: �, �`�v :..�SS Q n,Q,!' �GL�L—I � � SPA�v�1 <br /> Phone (day): G� �-. <br /> Address: �. Cit : 'g,r'O� •�1 ZIP: s L/S <br /> Email and/or Fax — /lc �, �, o.-. . Co�-�- <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: ;,� �i� r��""wG S i� C' ��+�. i 2 G. <br /> Estimated Construction Valuation of Pro (excluding land) $ S DO � D�D <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 refus to su I the information, e a lication ma not be issued. <br /> � ^ <br /> ApplicanYs Signature: q �_ Date: ( ] <br /> Last Updated: 05-04-2009 <br />