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City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: a. PO Box 66 Permit number. D l 00 Q Crystal Bay, MN 55323-0066 Date received: hl StreetAddress: Received by: c~ 2750 Kelley Parkway Plan review fee: Orono, MN 55356 `Main: 952-249-4600 Fax: 952-249-4616 w_ww.ci,orono.mn.us Total Fee: This application form must be completed in full and all required information must be submitted. Incomplete a�cations will be returned. (Please print) GENERAL INFORMATION: Job Slte Address: Will this be a Parade of Homes, Remodels Showcase Home or other Display Homed U Yes El No If yea,a special event permit is required w>th Police Department and City Coundl approval 60 days pdor to the event. Shuttle bus sennas will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR l APPLICANT INFORMATION: Name: (A l b A'T V*E 2 --T k1 ]E)c TE P/0 R S State License# Ib6, 6 c� Expiration Date: 3 3/ Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: 577-S?e/ (office) (cell) Mailing Address: �Dl //7 ha le� City: ZIP: // Contact Person: 4all JA Applicant is: Contractor / Homeowner (circa one) Email and/or Fax: (, g -� ��1?7 PROPERTY OWNER INFORMATION: �1 Name: i A) E L IN y gy r- R E Q T 5 a Phone(day): �'�, _ r - r , P3 Address: y 'I of K ev9 Vo City:&7 ZIP; 5 25"� Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑Remodel ❑Water Damage MCWD review&hermits: ❑Window(s)s Minnehaha Creek Watershed District(MCWD) wO ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd i]Siding ❑Restoration ❑Other:(specify) Deephaven,MN 55391 XRe-roof ❑Fine Damage Phone: 952-471-0590 Fax: 952-471-0682 wwww.minnehahacreek.om _Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ d 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 upon failure to do so,the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is Information which generally cannot be given to the public but can be given to the subject of the data. Confidential data ' rmation which genera cannot be given to either the public or the subject of the data. Our purpose and into use of thi ' ormation is to a wally update our records and records of other governmental agencies required b law. ou refuse to su I he info do the applicaWn mav not be issued. Applicants Signature: r Date: Last updated: 03-01-2011 Tay.. i