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f ;� � City of Orono <br /> Building Permit Apptication for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailrng Address: permit number. ���-� �'b <br /> O.�0�.O PO Box 66 �� /D <br /> Crystal Bay, MN 35323-0068 Date received: <br /> Street Address: Reoeived by: <br /> 2750 Kelley Parkway Plan review fee: <br /> ����o�� Orono, MN 55356 (� � <br /> Total Fee: `�' � <br /> Main: 952-249-�{i600 Fauc 952-249-4616 �vww.a.orono.mn.us �� <br /> This application form must be completed in fuil and all required information must be submitted. <br /> Incomplete applications witl be returned. (P/ease print) <br /> GENERAL INFORMATION: /'�� �� / /,�� .�� /Y1 . � �� 9 � <br /> Job Site Address: L Ci (.�V ��� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o <br /> If yes, s special eveM permlt is reqWied with Police Department and Ciry Councll approva!d0 deys prfor to the ever►t. SbuttJe bus service !!be <br /> required unfess applicant demonsAretes sufl�cfent on-s�te parWng is eveilable. Non-pertnitted evenfs wfll not be allowed. <br /> CONTRACTOR 1 APPLIC NT INFORMATION: <br /> Name: � G� <br /> State License# 1� ' ;� 3 Expiration Date: <br /> Phone: - office cell <br /> Mailing Address: �� � �Ur ' Ci : ' . ZIP: - <br /> Contact Perso �, Applicant is: on c or / Homeowner �ci�eie o�� <br /> Email and/or�ax� - - <br /> PROPERTY OWNER INFOR TION: <br /> Name: � � <br /> Phone(day): G ,J •� ,,�i <br /> Address: Ci ZIP: l <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8 pernnits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Stortn Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> ❑ Siding Fax: 952-471-0882 <br /> ►� <br /> e-roof ❑ Fire Damage www minnehahacreek.ors� <br /> Overall Project Descrfption: �'— cl�' ^ <br /> Estimated Construation Valuation of Project(excludin land) $ GLL� _ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> � • Agrees to provide all information required or requested by the Building Oepa�tment; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicarrt recognizes that they <br /> are solely responsible for submitting a complete application being eware that upon failure to do so,the staff has no altemative <br /> but to reje�t 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 privete 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 Info�mation which generally cannot be given to either the public or the subject of the data. Our <br /> pe u�ed bn awtelfdou efuse th u�nf I he�irifoirmationnth Ila u�lication mae ot�beessued�rds of other govemmental agencies <br /> �� � . <br /> . � <br /> � <br /> Applicant's Signature: i <br /> � '�� Date: �, � <br /> Lest Updated: 05-04-2009 <br /> Z 'd SGOi►S9S i S9 i ou I �t empe� eE0 �60 0 t OE ��d <br />