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� <br /> � <br /> � <br /> .�. City of Orono � '� <br /> s Building Permit Application for Internal Work fi �c � <br /> (windows, doors, siding, re-roof, etc.) ��`' �� <br /> Mailing Address: Permit number: ��� <br /> �,�,�. PO Box 66 � <br /> � � O Crystal Bay, MN 55323-0066 Date received: N; <br /> ,a �''�'"� Received b � <br /> � 3��.; �, � Street Address: y� � <br /> �'.�, ° �� �ti�' 2750 Kelley Parkway Plan review fee: `�' <br /> '��.gESHo4� Orono, MN 55356 �� � <br /> v <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: ,F� <br /> Job Site Address: =`-�� ��F�r�;�H 1 c-t_ �-v,�D <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/APPLICANT INFORMATION: <br /> �, <br /> Name: -�—v�,; ��C�c=2_t��-S , Lf,� <br /> State License# Zv�3�,v��� Expiration Date: 3— 3i�- 2or'�— <br /> Phone: (z�zz�— � � office cell <br /> Mailing Address: ��� t J�,N�;3� ,,,�� City: (No�,,,�v��� ZIP: S�s�7 <br /> Contact Person: T2�=�,<,r._ -�-�;S Applicant is: o7�tra�tor / Homeowner (Circle One) <br /> Email and/orFax: /—��8- ;e�r �-- �3�.,�� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �'�� `� �nnt-r i'�vb�f�ivr >> <br /> Phone (day): �?�1-- �3' i�l-� � <br /> Address: 3�� J,on_�,�,�/-�it� 2�,�,c City: �,/1��,,� ZIP: S.S S�/ `� <br /> Email and/or Fax <br /> PROJECT INFORMATION: � <br /> Type of Project: Any earth movement may require � <br /> �� <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 /> e-roof ❑ Fire Damage www.minnehahacreek.orq <br /> verall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ -�� c5cx�--� Y�� <br /> :� <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 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 s� <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 t he information,the a lication ma not be issued. � <br /> ApplicanYs Signature: Date: �� `�" �J`���- '� <br /> � <br /> .a <br /> t <br /> Last Updated: 05-04-2009 � <br /> � <br /> � <br />