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City of Orono Building Permit Application Mailing Address: Permit number: O PO Box 66 Crystal Bay, MN 55323-0066 Date received: a Street Address: Received by: 2750 Kelley Parkway Plan review fee: iOg� Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: y20 eon�(_^WK R� 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. CONTINFORMATION- Name- /APPL � _a j& 5 D T I me: �th, �U t V11 State License# 201A 9 xpiration Date: 3/11 /01 Phone: of 2- 4 - 7 Z 1 office) t,I'2-Z5(-f(710 cell Mailing Address: __j tco Cit , r ZIP: -5-5331 Contact Person: Y,4.r�y\f Applicant is: ontracto / Homeowner (circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: ne, Phone (day): Lc�� Address: Ll- 0 ► Q�ka�,,� City: s ZIP: Y5 35(,o Email and/or Fax 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.org Estimated Construction Valuation (excluding land) $ . 000 APPLICANT & OWNER ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department, • Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete. • The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by City Staff, consultants or agents, for purposes of investigation of this request. • Some or all of the information at y u are asked to)n, he de on this application is classified by State law as either private or confidential. Private data isJimormati n whichI annot be given to the public but can be given to the subject of the data. Confidential data is imatio w ich gnno a given to either the public or the subject of the data. Our purpose and intended use is inf r tion ily date our records and records of other governmental agencies re uired b law. If ou refus su I e info lication may not be issued. Applicant's Signature: Date: �� Q ( Q� Owner's Signature: Date: