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� `P' � � '� , �+:`. �• } '� � � City of Orono � �� ��_r , : Building Permit Application for Internal Work .� (windows, doors, siding, re-roof, etc.) � � _� Mailing Address: �, �,L,�,� PO Box 66 Permit number: D/(�- ab7/ � Crystal Bay, MN 55323-0066 Date received: � /D w, � � Q � ,� �'�a�-��" s. I StreetAddress: Received by: °r. G .,� I �' � '� s� G� 2750 Kelley Parkway Plan review fee: '� �t9'kESH04'� Orono, MN 55356 �' Total Fee: (D�l �� ; Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us T � � .: This application form must be completed in full and all required information must be submitted. � � ` Incomplete applications will be returned. (Please print) � `z GENERAL INFORMATION: � �` � Job Site Address: Z � � � ��-� c�_� ��'�. `� � �..��c c� �� ;, ' Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No ;� S.. 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 ;;,:, � required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. Yx � CONTRACTOR/APPLICANT INFORMATION: ;� Name: �'1 ��..�c, � �o F`.il< ; " State License# �� . Expiration Date: 3 / � � � ,� Phone: �� z 7 y y'� office) cell �� MailingAddress: � � ( �u�� „�,�< <f �f/. Cit : �,��J� r�� ZIP: S-�G � �� ��. Contact Person: Applicant is: <<•�ar.tn�; Homeowner (Circle One) -� t� �' Email and/or Fax: _ �� 6. PROPERTY OWNER INFORMATION: �`� �, , �� �;� Name: lc�.� �, -t � c;n � � ` Phone (day): 'S � � �•� Address: �_� l l wS�� `��ot� City: �'�^ u •�v ZIP: �S�l�� �� Email and/or Fax `^'� �;., ;;J p; �: �� c::�:. �,,. � , PROJECT INFORMATION: � Type of Project: Any earth movement may require �:,`-' MCWD review&permits �`�� ❑ Door(s) ❑ Remodel ❑Water Damage � Minnehaha Creek Watershed District(MCWD) tr ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd 'f'� Deephaven, MN 55391 �� ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 � Fax: 952-471-0682 � e-roof ❑ Fire Damage www.minnehahacreek.orq " Overall Project Description: r —,-�� ,� � �� Estimated Construction Valuation of Project(excluding land) $ S C.�, o� �'� 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 applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative t ~� but to reject it until it is complete; �.�, • Some or all of the information 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 public 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 �4�; 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 refuse to su I the information,the a lication ma not be issued. �:` �. . L � � /� � `/ t0 � Applicant's Signature: a.�' �� Date: ,E �.;. �-; Last Updated: 05-04-2009 . � , � _., .� _�., �._ , , _. . � �� .». .k., �..._ a� �. _. .n� u� ._. .e.