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, � City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) 7�i���� <br /> --_-> Mailing Address: <br /> Permit number: �0 j(— <br /> ;�%�,0,���, PO Box 66 <br /> ��`�� Crystal Bay, MN 55323-0066 Date received: J'r <br /> ,; <br /> ��� � �- ��' Received b <br /> �!��,� .l�r�,� ._, ,�;; StreetAddress: Y� <br /> \�',�, �{�����;, �ti!� 2750 Kelley Parkway Plan reviewfee: .7� <br /> � ' ''��f�g�� Orono, MN 55356 �OL��Dd��3 <br /> 9kEsx� <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: ��.�Ij �JV iv i�i •r�� �j ��'e�!{ <br /> Will this be a Parade of Homes, Re odel s 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 se ice will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ���ti ��j^�f� �i�✓�r�E'Y.5 f �1'1L . <br /> State License# + -�������� �- Expiration Date: �,�_ f��-��� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 �)L� <br /> Phone: ��'t�� -1��(�- --r,_��j� (office) (cell) �1 ��5� <br /> Mailing Address: � �2 " n� C,�, "' � City: ' � � ZIP: �� "� ���'' <br /> Contact Person: � Applicant is: ontrac or / Homeowner (Circle One) <br /> Email and/or Fax: , � y-� �-� <br /> PROPERTY OWNER INFORMATION: / • , ��,I <br /> Name: �IV i ��ll{1 vl �-�I� r !�",�.,��YY1 ���( ` T'[ �k' <br /> Phone(day): - _ � �' ^� — ,, <br /> Address: f Cit �� <br /> :�' v� � � "l� Y: L�`V� �� Z ZIP: ��2j�' <br /> Email and/or Fax 'S yy�� � (a � � <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�permits: <br /> ❑ Door(s) f�Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑ Restoration ❑Other:(specify) Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: SeQ, J�'t"(�(,�.O,�Q SC�Q� 0� (�.?8�� <br /> Estimated Construction Valuation of Project(excluding land) $ (,p��pQQ <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 <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 o su I t infor ation,t e a lication ma not be issued. <br /> ApplicanYs Signature: LU � Date: ���/��� <br /> Last Updated: 03-01-2011 <br />