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' � * City of Orono <br /> Building Permit Appiication for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �O� Mailing Addiess• <br /> PO Box 66 Pemiit number. <br /> � Q Crystal Bay,MN 55323-0066 p��N�: <br /> � Stieet Address: Received by: <br /> 2750 Kelley Paricway Plan review fee: <br /> ��� Orono,MN 55356 <br /> Main: 952-249�60p Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: �� "7 � <br /> This a�lication fiprtn must be c�ompleted in fuil and all requir�ed ir�formation must be submitted. <br /> Incomple�e appNcations wiil be r+etumed. (Please pri�►t) <br /> GENERAL INFORMATION• / <br /> Job Site Address: �,�� �,�,/,C !i � ����v� <br /> WII this be a Parade of Homes, Remodelers Showcase Horr�or other Display Home? Yes No <br /> 1f Y'�,a spec;ia!et�►t permit is�qulnsd w�lh PdiQe Depan�nt and City Courra/app�va!60 daYs Prtor to the event. ShuKle bus � <br /> iequired unless appl'�t darnor�t►ates suA�nt a►-site paAdng is availab/e. Non-P�mi�events will iwt be al/owed. <br /> CONTRACTOR/A ANT INFO T1QN- <br /> Name: .���- , �� <br /> State Lioense# �� � � �� /� <br /> Phone: - ��a� e: .� <br /> Mailing Address: : o�� C . �� � , ZIP: � �I <br /> Contact Person: . / ��t� plicarrt is: Contra or / H eowner <br /> Email and/or Fax: �ar�.a»l <br /> PROPERTY OWNER I FORMATION: C„!�e � <br /> Name: o <br /> Phone(day): <br /> Address: a h �!/i��/� C' ; �id ZI P: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: <br /> Any�rlh movement may require <br /> ❑Door(s) ❑Remodel MCWD revisw S permiCs <br /> ❑Water Qamage <br /> ❑Window{s) �R��� Minnehaha Creelc Watershed District(MCWpj <br /> ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑Restoration ❑Other.(speafy) �Phaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Re-roof Fax: 952-471-0682 <br /> ❑Fire Damage www.minnehahacreek ora <br /> Overall P Descrlptipn: <br /> Estlmated Consbuction Valuatbn of Project(excluding land) ; <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all iniormation requined or requested by the Building DepaM�er� <br /> • Cerafies tt�at the information supplied is true and oomect to the best of hislher knov�Aedge. The applu�nt reoognizes that they <br /> ar�e solely►+esponsible for submit6ng a complete applir.ation being awane that upon(ailure to do so,the staff has no altemative <br /> but to r+ejed R urrtil it is complete; <br /> • Some or all of the informatlon that you are asked to provide on this application is dassified by State Iaw as either private or <br /> confidential. Private data is information which generalty cannot be given to U�e public but can be given to the subject of the <br /> data• ConfideMial data is infortnation which generally cannot be given to either tl�e public or�e subjed of the data. Our <br /> purpose and irrtended use of this information is to annually update our records and reoords of othe�govemmental agencies <br /> uired b law. If u refuse to su I the infortnation the a lication ma not be issued. <br /> ApPlicant's Signature: �„—b--� — D�: <br /> �ast updacea: o�-oa_2oos <br />