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• G�,e�� ��55 <br /> . � C �a3.�D <br /> City of Orono � <br /> Buildin Permit A lication for Internal Work <br /> J pp <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �l� O�J�,_/ <br /> ,; g,0,�. PO Box 66 <br /> „ O Q,' Crystal Bay, MN 55323-0066 Date received: <br /> ',�,� l��r�l� _ �,�� StreetAddress: Received by: <br /> ��\�',�, ;��;"����� ti�' 2750 Kelley Parkway Plan review fee: ���. �� <br /> ���L.vkEs�K g�G'� Orono, MN 55356 � 00O <br /> ____'" Total Fee: / <br /> Main: 952-249-4600 Fax: 952-249-4616 ��rrw4v.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: �; �=' �- ���- ,,,�j ��.;��; ';��� , J �,�3"� � <br /> Will this be a Parade of Homes, Remodelers 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 evenL Shuttle bus seivice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: i c� 4�,�_, i���-�t--1���I��� -� ►��oT �5, t-� ��-(�T <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: C l����"� <br /> Name: ���c�� /su-j-��Tt u.� �'�, ��.SG . <br /> Phone (day): <br /> Address: ��'�3 �j. p�--��..`3�,� City:GJ�X i� �i C��nZIP: �r7�j(L,(7 C� <br /> Email and/or Fax r;�,�; ���; �s? cC,sc�-x�,r-n, c��,--� <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.minr�ehahacreek.orq <br /> Overall Project Description: ( �!�-��� r�,��-,� <�� ��,--,T-�,�c� ���i�'i,�,�,� ���v�(��� <br /> Estimated Construction Valuation of Project(excluding land) $ I O`S ,���� c' <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 staf`tias 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 /> required by law. If you refuse to supply the information; ap lication ma not be issued. <br /> -- -- � — ---- – -- <br /> ApplicanYs Signature: , Date: i/�/l/ <br /> _ C� <br /> Last Updated: 05-04-2009 <br />