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� ���� <br /> -• City of Orono ° r ,,� ���► <br /> , . <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> ��g,�,�. PO Box 66 Permit number. � ) - �' � <br /> �� Crystal Bay, MN 55323-0066 Date received: �� �7�(��` <br /> , � .� � _ <br /> �s �,''i <br /> � , Received by: <br /> a �� (,�> = a, j Street Address: <br /> �'.�, � ������ �ti``'� 2750 Kelley Parkway Plan review ee: <br /> 19k�?'�o�� Orono, MN 55356 � <br /> �ESH_/ /� <br /> �— Total Fee. p3 v���V <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.ororto.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: 9'�j [t>C.t►.TT"� Q,c3�,p ,� <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 event. Shuttle bus service will e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: ��� C�M ��J <br /> Name: �C�.��. S C.��o <br /> State License# 153 Z Expi ation Date: <br /> Phone: 9'S 2- �'Z�l� oo�(3 (office) �yS 2- G Q l - 34�l (cell) <br /> MailingAddress: 3gop G,.o,�,L��,e,,v�. �4�� City: 57. Lc�uis P..al�(ZIP: c�� �{Z � <br /> Contact Person: N(i(�E jas'�' Y52�Z37� 73Y3 Applicant is: on rac o / Homeowner (CircleOne) <br /> Email and/or Fax: g52- 2'Z�� DO�i 3 <br /> PROPERTY OWNER INFORMATION: <br /> Name: D►a.v� �- �,o..-r-r Y $cLtS t—o v`' <br /> Phone (day): 6[Z, $O! - 5(6 7� <br /> Address: q4 GQc�v�tt�' Roa��O 6 City: Wp�Z.�T'p► ZIP: 55,'�91 <br /> Email and/or Fax j��p,UL�b� I�D G-�S . C OtiL <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: Z, �,,���p�y�,�b — REnn.o G 1�(��TC.6�`r�J �l� <br /> Estimated Construction Valuation of Project(excluding land) $ � DOfl "' tN cv�t�DcPx o'LZ(G. <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 al� 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 refuse to su I the information,the a lication ma not be issued. <br /> Applicant's Signature: ` Date: S 2 8� <br /> Last Updated: 05-04-2009 <br />