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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: coo C7 %,q <br /> OCL+O,�O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: U <br /> "a ��� �, I Street Address: Received by: <br /> �� GtiiS 2750 Kelley Parkway Plan review fee: <br /> SHO ly Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: <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: <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"I 6e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name. Tc,;,�AAc-71ryC�, <br /> State License# t <br /> `3E:Z,�L Expiration Date: <br /> Phone: (office) ( iZ - "W __ZL Q(o (cell) <br /> Mailing Address: 1 o c: v p4,� 1°i Cit x� ZIP: ,jhok <br /> Contact Person: � ��, �A� H Applicant is: ;, ontracto / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: 1D � -v\rim Cw N E�Phone (day): Sa- ti0 l-1 c 1-� <br /> Address: �Nb;��,�cpu kcgCity: L,;DWS Aa L6 ZIP: <br /> Email and/or Fax C� �\ ® M c-k; <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review & permits <br /> ❑ Door(s) ❑ Remodel 1 ®Water 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.o <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ i(} D00.00 <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 supply the information, the application may not be issued. <br /> Applicant's Signature: L Date: b CLQ <br /> Las`Updated05-04_2Opc <br />