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City of Orono <br /> - `' Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> O�,D,�.O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> � <br /> ,a �� �� s. Street Address: Received by: <br /> �',�, ' '� �titi 2750 Kelley Parkway Plan review fee: <br /> �;` L`�kESHo�`'� Orono, MN 55356 <br /> '`� Total Fee: <br /> � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> A <br /> ���`- This application form must be completed in full and all required information must be submitted. <br /> � Incomplete applications will be returned. (P/ease print) <br /> � GENERAL INFORMATION: �/ <br /> � Job Site Address: ��7"1 ��LC1�'�2 V��W �l/C% <br /> � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> y( !f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus rvic will be <br /> �' required unless applicant demonstrates sufficient on-site parking is avarlable. Non-permitted events will not be allowed. <br /> � <br /> �'-: <br /> �; CONTRACTOR/APPLICANT INFORMATION: <br /> ��:i Name: �55 �'�TC21U�, L� <br /> �.�; <br /> ��'; State License# Zpc(���Z Expiration Date: �_3 f_�� <br /> "� Lead Certification Number: Ex iration Date: <br /> ►2-.T'-3v35�3- 11 -U(�!S p� 3-l� 'Zo1� <br /> (for work on homes that were construcfed prior to 1978 <br /> Phone: ��-L,_�,� � 8(�(q (office) (cell) <br /> Mailing Address: ,�,,,� City: /�,c,n1l,q ZIP: -w $"�7 <br /> Contact Person: ---C"�L -�r,$,s Applicant is: ontractor / Homeowner (CircleOne) <br /> Email and/or Fax: g�� _ �4-Z— �(�(�' <br /> PROPERTY OWNER INFORMATION: <br /> Name: G�Ly4!(� .�"1_'1-fC12.�--= �R�t..��J73v2C� <br /> Phone (day): �p(Z— 60 — 181"7 <br /> Address: ?_'7'7S- 5��.�.-v'r�-w �J�u� c�ty: q�z�o,.� ziP: S'�'��� <br /> Email and/or Fax <br /> PROJECT INFORMATION: �r4iLr(�� I�•2�� <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> �F- www.minnehahacreek.orq <br /> �., <br /> �� Overall Project Description: <br /> "` Estimated Construction Valuation of Project(excluding land) $ <br /> �T', l�o,d�?-�� <br /> �z;: <br /> '`''' APPLICANT ACKNOWLEDGEMENT: <br /> �_ <br /> ��;- • Agrees to provide all information required or requested by the Building Department; <br /> i,, <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 ref e to su I he information, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �" 15—ZO 1� <br /> Last Updated: 03-01-2011 <br />