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r City of Orono a1XIJ Building ionilding Permit Applicat Mailing Address: Permit number: be a/o�_) 0,�\ PO Box 66 Crystal Bay, MN 55323-0066 Date received: \" Street Address: Received by: 2750 Kelley Parkway 1 n��jj Plan review fee: L9kRSIIO, Orono, MN 55356 �Y Total Fee: �( S Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us u + This application form must be completed in full and all required information must be submitted. SCi eg Incomplete applications will be returned. (Please print) GENERAL INFORMATION: , Job Site Address: Z_Wzo `�o✓�k�,y�� YAR Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: -MOO Cow-Ax.yC\ State License# NI A- Expiration Date: w(it Phone: qsz, y-+2, coo Wffieerrf*Mkt `5-2 Z2l,6 ,`/ (cell) Mailing Address: zc> Wvuz City: 0/_0Af(_\ ZIP: 36y Contact Person: --reyo Applicant is: Contractor Homeowner (Circle One) Email and/or Fax: 4--rcCd-n PROPERTY OWNER INFORMATION: Name: D 6)1" vue Phone (day): 9S2_, 221, 6yE Address: L6-zfs '@�kc,.y`�¢w Lc—M City: p✓-vNG ZIP: 55 Email and/or Fax --L�Q(50-, u y qf�s zvzV\6 PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑ Siding ❑ Restoration Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑ Re-roof ❑ Fire Damage www.minnehahacreek.o Overall Project Description: �cn.c.Qv\ , �cl.� v)d¢r Q05+IVN� ,2c- d.A t 2 Estimated Construction Valuation of Project(excluding land) $►Sao APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that 91=-failure to do so, the staff has no alternative but to reject it until it is complete; �begivepnl Some or all of the information that you are asked to vion is classified by State law as either private or confidential. Private data is information which erally cannot to the public but can be given to the subject of the data. Confidential data is informationgeneral nnot be given to either the public or the subject of the data. Our purpose and intended use of this ' rmation is wally-Uecords and records of other governmental agencies required by law. If you refuse supply the ' rm on,the appfca ' n m not be issued. f' ` 2, Applicant's Signature: Date: �r (o �f