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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: 02009-0631.8 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Received b <br /> Street Address: y <br /> F, o~ 2750 Kelley Parkway Plan review fee: <br /> � ti <br /> L9xES140 Orono, MN 55356 _ �l <br /> a/ 3�7 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: I <br /> This application form must be completed in full and all required information must be submitted. rn-S3 l-tg-LYYI <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 3705 Ac-)6Q le <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 to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: J <br /> State License# 0 S l$ 1 L4 10 Expiration Date: 3—_,A0,,0 <br /> Phone: 617- VI(a-49L,7 (office) (cell) <br /> Mailing Address: S,)L- t53' plc41_{ City: ZIP: 55-4.7 V <br /> Contact Person: Applicant is: Contractor/ Homeowner (Circle One) <br /> Email and/or Fax: Joe . c4(eh ha _en <br /> PROPERTY OWNER INFORMATIO <br /> Name: 1-041 <br /> Phone(day): <br /> Address: 10/0 /.i,,,110 6.,o VIPc✓ Or/ve City: z9r'Pily ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: ADD Av CUY y * W1 I S CO (� <br /> Type of Project: Any earth movement may require <br /> MCWD review& permits <br /> ElDoor(s) remodel El 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.arg <br /> Overall Project Description: rwlao C n <br /> Estimated Construction Valuatio of Project(excluding land) $ 110,C100 <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 /> • 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 /> required by law. If you refuse to su e rmation,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 05-04-2009 <br />