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�.G�-"�- <br /> � —b- ID <br /> - c� f a �`5� � <br /> ty o Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permit number: ;Z,O//—b0�/.� <br /> O�v�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ,� � <br /> � a Street Address: Received by: <br /> � " G'tiF 2750 Kelley Parkway Plan review fee: <br /> �'�x'Esxo�''� Orono, MN 55356 <br /> Total Fee: �?�S��pb <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: 2 O F3�j s �/�y-�S �v a ra k o _. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,�'No <br /> If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ..r M. e 'I � L� <br /> State License# Expiration Date: 3 - ,3!- Z G 1� <br /> Phone: - �/ - ♦ office - - ' z y cell <br /> Mailing Address: �T1 ,¢y„���5��L�¢,� City: ,� ,,�,,,'�� ZIP• S�i'y34 <br /> Contact Person: ��r}v/ w i.v�,�,s Applicant is:( �Contractor� / Homeowner (Clrcle One) <br /> Email and/or Fax: �,�,�5 � T�,�,r �,�s,����a C b�__.-_.--' <br /> PROPERTY OWNER INFORMATION: <br /> Name: T�.--�..� �/l 6��E <br /> Phone(day): y�� ��2 S-2 �..j <br /> Address: � n�6� s,� �,c� .,¢� City: �� � ��.�, ZIP: <br /> Email and/or Fax �. <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) MCWD review&permits <br /> emodel ❑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.or <br /> Overall Pro'ect Descri tion: ,— G � � y �� <br /> Estimated Construction Valuation of Project(excluding land) $ E � Ova <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Departrnent; <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,the a lication ma not be issued. <br /> ��� /,,/ <br /> Applicant's Signature: C �i7/�c Date: �-3- /C� <br /> Last Updated: 05-04-2009 <br />