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ti <br /> City of Orono ��� <br /> � <br /> .� , <br /> � Building Permit Application for Internal Work � <br /> (windows, doors, siding, re-roof, etc.) ;'�� <br /> y� <br /> Mailing Address: Permit number: 02�1�•���� ' <br /> ��,�,�.� PO Box 66 ��� � <br /> Crystal Bay, MN 55323-0066 Date received: � °� <br /> � <br /> a �p���;;, s. � Street Address: Received by: � <br /> 'S',�,� �� �� ��,� 2750 Kelley Parkway Plan review fee: ;� <br /> �ykESHO�' Orono, MN 55356 � ;� <br /> Total Fee: /� � �j, � <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: ���� �� ppq� <br /> Will this be a Parade of Homes, Remodelers owcase Home or other Display Home? ❑ Yes o <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 rs available. Non-permitted events will not be allowed. i�.; <br /> CONTRACTOR/APPLICANT INFORMATION: ;� <br /> Name: l4/� SeA so nl �en�oa�e�.v� Anic� f���/4oair � <br /> State License# a p3�g ��/ Expiration Date: � <br /> Phone: loi� - q (- 6 / office /�-9G 8'�//� cell <br /> Mailing Address: c,n,.� S , GJ Cit : ZIP: $S3d <br /> Contact Person: Applicant is: ontractor Homeowner (Circle One) <br /> Email and/or Fax: __ i__A�_,SeAso�J � Co�+c.a5i,NQT <br /> � <br /> PROPERTY OWNER IN RMATION: /� -. <br /> Name: R/.s t C'ARk�2, (..•45� � <br /> Phone (day): Sa- 76- �/ \ � � <br /> Address: a/�o �uq�2 oocQs k-�2 City: �jRpc�✓n ZIP: S-5 3S-(� � <br /> Email and/or Fax " <br /> �� <br /> PROJECT INFORMATION: ;� <br /> Type of Project: Any earth movement may require � <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage � <br /> '� <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 /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq � <br /> Overall Project Description: oa�'�� - ��Q :� <br /> Estimated Construction Valuation of Proje t(excluding land) $ � <br /> .:� <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: � <br /> • Agrees to provide all information required or requested by the Building Department; � <br /> � <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 /> `; <br /> • Some or all of the information that you_ ed to provide on this application is classified by State law as either private or � <br /> confidential. Private data is inforrrlatron whic generally cannot be given to the public but can be given to the subject of the �� <br /> data. Confidential data is infos�tion whic generally cannot be given to either the public or the subject of the data. Our �- <br /> purpose and intended use o his informa�ion is to annually update our records and records of other governmental agencies � <br /> re uired b law. If ou ref e to su I xtie information, the a lication ma not be issued. <br /> � <br /> ;, _ _ __ �- . / � <br /> ApplicanYs Signature: Date: .2m /O a <br /> � � � <br /> �� <br /> Last Updated: 05-04-2009 � ' <br /> `.� <br /> `::� <br />