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���_x �... <br /> L—L^ C� L�� <br /> City of Orono � � �a _ <br /> ' Building Permit Application for Internal Work ���'p � �� � <br /> .� <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: c���0 �� 71 <br /> �L,�,j� PO Box 66 /�/ <br /> Q �\ Q Crystal Bay, MN 55323-0066 Date received: b <br /> a ��3r3 <br /> '���T;;� a Street Address: Received by: <br /> �'.� � "w� Gti`� 2750 Kelley Parkway Plan review fee: 8• <br /> r�kESHo4� Orono, MN 55356 ��/O —vU� ; <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: 2�� �C,p�,��,��(;r;, 1�r ,1t` ,� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service il/be '`4� <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. t� <br /> CONTRACTOR I APPLICANT INFORMATION: � <br /> Name: �c, ,:�� :� <br /> State License# �� Expiration Date: ?. Z { <br /> Phone: _ C �'� (office) cell `� <br /> Mailing Address: �� : City: 5T, q.UL ZIP: <br /> �� <br /> Contact Person: {.(N �� � Applicant is: on rac� / Homeowner 1Circle Onel <br /> _�.,.,.,�.��..- � <br /> Email and/or Fax: l�,1,.�" (- �eC1r ��7�.,,`� � <br /> .,� <br /> r. <br /> PROPERTY OWNER INFORMATION: ;: <br /> Name: Zi CNf�-� ��OMa(E�1�- <br /> � <br /> Phone (daY)� �3.r2 - d7� - �'77Cc� ' <br /> Address: � I � �Ut���2_c.t�k,.�.1r3 �� • ..,�ay City: �Q.C� � . ZIP: ...�-'r.� `.���r <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 /> 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.or4 �� <br /> k;, <br /> Overall Pro'ect Descri tion: < '� ''� <br /> J p NV�xT �.",�CE'�7V lr�.,t� N/ `!� �'�-�'.�'7��N �:;�,"�� G� <br /> Estimated Construction Valuation of Project(excluding land) $ .�r';�� . 4; <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 responsib�e 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 intende of this information is to annually update our records and records of other governmental agencies ,� <br /> re uired b law. If u refu su I th �nformation, the lication ma not be issued. �� <br /> ;�� <br /> ,:� <br /> ApplicanYs Signature: � � Date: � 2 �!�-��, �� <br /> Last Updated: 05-04-2009 <br /> . x <br /> �� ..�`�.x � _. ;,. <br />