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C i ty of O ro n o ��-� � <br /> . � ��� <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: a��0-dG 9� <br /> Og,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 9 d U <br /> ��,��. <br /> ,� �'�'' �4�:i �, Street Address: Received by: <br /> '�',�, 2 'e^ Gti�' 2750 Kelley Parkway Plan review fee: <br /> t.ykESHog� Orono, MN 55356 <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 returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: <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 be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPL ANT INFORM ION: � � <br /> Name: `� � � �` �1. `2aa � G� 0 <br /> State License# a � � p Expiration Date: 3! % <br /> Phone: — a. office O � `�`�..� cell <br /> Mailing Address: 5 S. - � Cit : S � �c.� ZIP: � / � <br /> Contact Pers � J m s Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/ Fax: �' S( �� U '— O U S�.S� <br /> PROPERTY OWNER IN ORMATI�N: /� � <br /> Name: �l41v�vu Gt-r� ,, �v Vj-�',� <br /> Phone (day): T / <br /> Address: � � a ay �t � City: �S ,Q o/Lo ZIP: s� �� � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�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 /> e-roof ❑ Fire Damage www.minnehahacreek.orp <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excPuding land) $ � <br /> APPLICANT ACKNOWLEDGEMENT: �— `( ,� <br /> • Agrees to provide all information required o equest y the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowle�ge. 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 r fuse to su I the information, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: � � ` � <br /> . � <br /> Last Updated: 05-04-2009 <br />