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. ` City of Orono <br /> ' Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �� Mailing Address: Permit number: <br /> 'Qv�,�\ PO Box 66 <br /> /Q s Q�\ Crystal Bay, MN 55323-0066 Date received: <br /> � il\\K� � <br /> 1� �'r���". a, � Streef Address: Received by: <br /> �`�� rZ �� ti <br /> �, �,�� 2750 Kelley Parkway Plan review fee: <br /> ��rf'�° �' g�/ Orono, MN 55356 ; <br /> ESH� f <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 INFORMATI� , �s6� � // /� � <br /> Job Site Address: 7 �, ��� �� <br /> Will this be a Parade of Homes, Remod rs Showcase Home or other D splay ome? ❑ Yes � No <br /> /f yes, a special event permit is required with Po/ice Department and City Counci/approva/60 days prior to the event Shuttle bus service wil/be � <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be a/lowed. ;� <br /> CONTRACTOR/APPLICANT INFORMATION: . � <br /> Name: �//SEo� ��», s r�.< <� ,�� <br /> ;. State License# �;c,�L�3i S � �i� Expiration Date: 3- // -c� � <br />�� Phone: � _ c�-� � � �v� office cel� � <br /> Mailing Address: S y S � �.�, e �J3 Cit : m � ,,,„ ZIP:�S,3�S t � <br /> Contact Person: ��,te C .o�l5�h Applicant is: r / Homeowner (Circle One) � <br /> Email and/or Fax: ��3 _�j7�_l� ov ;� <br /> � <br /> PROPERTY OWNER INFORMATION: , � <br /> Name: C,�aj� Morz �� o�; lrla�c.- L�1r,,;b,., � <br /> Phone (day): `�c,3`t�t -S?�� <br /> Address: 3 4 S Spr�M �/l d City: O,c�n c7 ZIP' ? <br /> Email and/or Fax <br /> � <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel MCWD review 8�permits <br /> ❑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 /> �-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: j<� P � �, f F �c.� (Z.�� <br /> � � �l S !��:u <br />� Estimated Construction Valuation of Project(excluding land) $ �/U o o a V� <br /> `' APPLICANT ACKNOWLEDGEMENT: <br />�� <br /> � • Agrees to provide all information required or requested by the Building Department; <br />��u <br /> a ' Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> � °� <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 /> � <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 ann ally update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the informat' n t e a lication ma not be issued. <br /> �j <br /> Applicant's Signature: ,t-� Date: �� ��r C:.� `"� <br /> Last Updated Q5-0�-200� <br />