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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. (�(/ <br /> 0\� PO Box 66 <br /> Q 1� Crystal Bay, MN 55323-0066 Date received: <br /> �i <br /> it Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> Main: 952-249-4600 Fax; 952-249-4616 v"vi.ci.orono.mn,u5 Total Fee: /,O <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: 7` 6- /�' r 'e� �a <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 approval 60 days prior to the event. Shuffle 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: i A-4, <br /> State License# 0 Expiration Date: <br /> Lead Certification Number: --r <br /> /'') i>,� Expiration Date: <br /> (for work on homes that were constructed pitbi to 1978 <br /> Phone: en ?6;3v (office) jv2 - (ma y' (cell) <br /> Mailing Address: Gt City: r Cc,:z'ZIP: /J <br /> Contact Person: Applicant is: Contractor V Homeowner (circle one) <br /> Email and/or Fax: �- �• � ����`r �.�� ��� �i�--�� p��..� <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): —4 ? <br /> Address: ;fy,, — City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: <br /> Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> ❑Window(s) ❑ Repair Damage Minnehaha Creek Watershed District(MCWD) <br /> otren <br /> 18202 Minnetonka Blvd <br /> ❑Siding ❑ Restoration ❑Other: (specify) Deephaven, MN 55391 <br /> Re-roof ❑Fire Damage Phone- <br /> Fax: 952-471-0682 0 <br /> wvw.m in ne ha hacreek.oro <br /> Overall Project Description: <br /> - <br /> Estimated Construction Valuation of Project (excluding land) $ v <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 ou refuse I the.ipfoqnation,the aR ication av not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 03-01-2011 <br />