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;M Cit� of Orono :� �� - Building Permit Appiication for Internal Work � � (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: pZ�` , f O�v Q,�O PO Box 66 Crystal Bay, MN 55323-0066 Date received: � l � ��,;- Received by: � � ;,, F Street Address: h �nt � ��ti 2750 Kelley Parkway Plan review fee: '� �Esxo4`' Orono, MN 55356 ,, Total Fee: � ��D,� � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. � Incompfete applications will be returned. (Please print) � GENERAL INFORMATION: a Job Site Address: �j�j O �-��, �j s 1�a 2��, Q �,(p ►'Y1/'l� " Will this be a Parade of Homes, Remodelers Showcase Ho e or other isplay Ho e? ❑ Yes No � !f yes,a specral event permit is requrred with Police Department and City Council approval 60 days pnor to the event. Shuttle bus se ice will be � required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permitted events will not be aflowed. -� ,'� CONTRACTOR I APPLICANT INFORMATION: Name: � • �,Ca.+-.r�e�,C.! � C.d �,-�� State License# Zd�,3� 9 9 8 Expiration Date: � _3 I - Zo t Z � Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (o�Z_ Z$ � _ ?(� g -� (office) 9 5 Z -�l.l t —7 c�5 9 (cell) Mai(ing Address: 3 0� S �� City: a„� ZIP: 5 3 8 Contact Person: �, ��--� �� Applicant is: n r cto Homeowner �c��ie one� k Email and/or Fax: ,;� . � PROPERTY OWNER INFORMATION: � Name: � T v+� � Phone (day): � S Z - --705 I 2 -759 - �11! j � Address: c� � �� , � City: ZIP: � Email and/or Fax � � ;.��, PROJECT INFORMATION: Type of Project: Any earth movement may require f� ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) � ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Si ing ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 ^; Phone: 952-471-0590 � Re-roof ❑ Fire Damage Fax: 952-471-0682 � www.minnehahacreek.orq � Overall Project Description: ;� Estimated Construction Valuation of Project (excfuding land) $ 5 0 o O, r��j � � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; `� • Certifies that the information supplied is true and correct to the best of his/her knowledge. The appficant recognizes that they � are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternafive � but to reject it until it is complete; � • Some or all of the informafion that you are asked to provide on this application is classified by State law as either private or ;� confidential. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the .� data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our � purpose and intended use of this information is to annually update our records and records of other governmental agencies re uired b law. If ou refu e to su I the i formation,the a lication ma not be issued. a Applicant's Signature: � � Date: 8 J 1� Last Updated: 03-01-2011