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1 <br /> . <br /> City of Orono w <br /> � Building Permit Application for Internal Work ;� <br /> (windows, doors, siding, re-roof, etc.) � <br /> Mailing Address: � <br /> O��,�.0 PO Box 66 Permit number: K <br /> Crystal Bay, MN 55323-0066 Date received: � <br /> � � Received by: <br /> �� <br /> ,� ��..� �, Streef Address: r' <br /> '�',�, '� A" �ti 2750 Kelley Parkway Plan review fee: " <br /> t�kESH�g'� Orono, MN 55356 ° <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: L/(� ��ib� ��-.� �'�r <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 fo the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wilf not be allowed. <br /> CONTRACTOR/APPLICANT INFORMAT ON: /�/ t' <br /> Name: ������� �w����e�S,�r �� ,�ii/Cl+�� z: <br /> State License# Expiration Date: �-3� ��i/ 'd <br /> Phone: �y5-�C1S�� p� (office) (cell) ;� <br /> Mailing Address: �. Cit : � ZIP: � <br /> Contact Person: ���� Applicant is: ontractor / Homeowner �c���ie o�e� � <br /> Email and/or Fax: � <br /> � <br /> PROPERTY OWNE FORMATI N: � <br /> Name: � � �J � <br /> Phone (day): - ''�' <br /> Address: y� `,h,�,�, � ��r �c� City: �r�j� ZIP: �,'j`z�,� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require � <br /> MCWD review&permits ?'� <br /> ❑ Door(s) ❑ Remodel ❑Water Damage "' <br /> Minnehaha Creek Watershed District(MCWD) <br /> :'`� <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd b�' <br /> Deephaven, MN 55391 � <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 :;h <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq �� <br /> O rall Project Description: � <br /> Estimated Construction Valuation of Project(excluding land) $ �a,�-.�_�+�� _ ((� <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 /> a <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 /> �k <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. � <br /> � <br /> � <br /> ApplicanYs Signature: � Date: �pb� jQ ���� ,� <br /> � <br /> ,,;: <br /> Last Updated: 05-04-2009 ' <br /> w <br /> 1 <br /> � <br /> '.: <br />