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.�f► <br /> City of Orono <br /> ' Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> ' Mai/ing Address: Perrnit number: <br /> O.¢,�,�.0 PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> a �� �, Street Address: Received by: ' <br /> ��, �ti�' 2750 Kelley Parkway Plan review fee`. <br /> l *v Orono,MN 55356 <br /> �EsH�fi' <br /> � Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.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�eturned. (Please prinf) <br /> GENERAL INFORMATION: <br /> Job Site Address: �� Cowv1 V► o w �P , r o r�o , I�n <br /> Will this be a Parade of Homes, Remodelers howcase 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 6us service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR ATIO <br /> Name: 00 . �0 � °� <br /> State License# Expiration Date: � <br /> Phone: ; q p�! office — - 3 cell <br /> Mailing Address: p0 e� Cit :51�.Lo �s ZIP: SS <br /> Contact Person: F r�� �}� n ow Applicant is: ontractor / Homeowner (CircleOne) <br /> Email and/or Fax: . q - �1.1�� � (v9 <br /> PROPERTY OWNER INFORMATIO • ' <br /> Name: �,�, o�.�!G -� a, r' S CC.�L, <br /> Phone(day): - - b1 /�� <br /> Address: �1�i C.o���✓n�r.� QjoL. �¢ City:VY'OY10 ZIP: �� � <br /> Email and/or Fax <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: � 1C�.�r� W 4 O��+S <br /> Estimated Construction Valuation f Project(excluding lan $ <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 altemative <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 refuse to su I the information a lication ma not be issued. <br /> ApplicanYs Signature: ���- Date: � �< � <br /> Last Updated: 05-04-2009 <br />