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f ` �//� � ?:,'�� � City of Orono r-� �--3 � Building Permit Application for Internal Work �� � (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: -�� Q �g,0,�.� PO Box 66 ; Crystal Bay, MN 55323-0066 Date received: /� l ' �q�� Received by: ° a �;,:z� s. Street Address: �'.�, �� ,ti`� 2750 Kelley Parkway Plan review fee: ``' t9kESH�g'� Orono, MN 55356 � Total Fee: � �� '`� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � � This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) �� GENERAL INFORMATION: Job Site Address: �Q�� ? � m Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No !f yes,a specraf event permit is required with Police Department and Cify Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: �-� Name: � e ) �J �; �" �1 n � State License# '�9�� xpiration Date: - -/ '.� Lead Certification Number: Expiration Date: � � (for work on homes that were constructed prior fo f 978 � .��,' Phone: ? 5-� �'� .Z' �77 (office) �1,2 ' �v—� -!� `� �`� (cell) '� Mailing Address: q ;^ �� City: ; , ;r-� ZIP: �,�� Contact Person: i e Applicant is: on ra r / Homeowner �c�r�ie one� '':� Email and/or Fax: , . ; �>- � U(��, �y . � � PROPERTY OWNER INFOR A��ON: � � I�� Name: ,�- G� _ _ � Phone (day): �j�z_ ^_ `' � Address: _-, � �� d-- � City: ,� i?F7G �, � ZIP:_,,;��'�, t '�i Email and/or Fax � � PROJECT INFORMATION: � Type of Project: Any earth movement may require � ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: r Minnehaha Creek Watershed District(MCWD) ;� ❑Window(s) ❑ Repair � Storm Damage 18202 Minnetonka Blvd ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 �� Phone: 952-471-0590 � Re-roof ❑ Fire Damage Fax: 952-471-0682 ?��, www.minnehahacreek.orq _Overall Project Description: �•�� Hr�.�>. ra��r�c.��ic�f � �,l i�c� ('e—rc'Xaf ' Estimated Construction Valuation of Project(e'cluding land) $j6.nC�c� � � � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; '� • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they `� are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative ''`� but to reject it until it is complete; � .r :� • Some or all of the information that you are asked to provide on this application is classified by State law as either private or � confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the '� data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our � purpose and intended use of this information is to annually update our records and records of other governmental agencies � re uired b law. If ou refuse to su I the information, the a lication ma not be issued. ;;;; , � ' ApplicanYs Signature: ��-t'�� s',�[�/ Date: � ` �(�� r t � Last Updated: 03-01-2011 � � �