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4 <br /> 09/29/2009 20:18 9524433205 KELLINGTON PAGE 01/01 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> windows, doors, siding, re-roof, etc. <br /> Meiling Address: Permit number: <br /> Cr Box 66 <br /> Crystal Bay, MN 65323-0066 Date received: <br /> } Street Address: Received by: <br /> rA <br /> ,F 2750 Kelley Parkway Plan review fee: <br /> Orono,MN 55356 <br /> Total Fee: � f <br /> Main: 852-249.4600 Fax: 952-249.4616 www, "o no.m s I <br /> illThis application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> NERAL INFORMATION! <br /> b Site Address: � -71+0 "Toto Voa. - <br /> I this be a Parade of Homes, Remodelers S owease Home or other Display Home? ❑ Yes ❑ No <br /> yes.a 4vdel event permit is required with f'olioc pcportmont and City Council approval 60 days prior t0 tha avpnt. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-eta parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I FORMATION: <br /> Name: �- <br /> State License _ Expiration Date: 3 - 31- A010 <br /> Pl�onc: offif-3. / 2- — cell <br /> fngAddress: ac"n Ci : Urc4rr'a ZIP: s3 6 <br /> act Person: ! i ,�•-, Applicant is: Contractor / Homeowner (circle ono) <br /> il and/ui Fax. CA-ctt:g.f/k�APERTY OWNER INFORMATION: <br /> e:ne(day): q� Cihl: orvH o ZIP:ess: --_;74o �oil and/or Fax <br /> PROJECT INFORMATION: <br /> r <br /> f Project: Any earth movement may require <br /> MCWD review&permits <br /> or(3) ❑Remodel ❑Water DamvOP <br /> Minnehaha Creak Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55381 <br /> T[RL <br /> iding C:1 Restoration O Other.(specify) Phone: 952.471-0590 <br /> Fax: 952-471-0662 <br /> -roof [I Fire Damage v M,minnehahicreek.orn <br /> Overall Project Descrl tion: <br /> timated Construction Valuation of Project(excluding land) $ <br /> PLICANT 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 ie 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 pumic or the subjw yr ti m dmta. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> reciuired by law, if you refuse to supply the' soon the application maX not be issued. <br /> plicanrs Signature: t®: �30 �a 9 <br /> t Updated: 05-04-2009 7 <br />