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L City of Orono G� Bluilding Permit Application for Intern l Work (windows, doors, siding, re-roof, etc.) Mailing Address: PO Bax 66 Permit number. a Crystal Bay,MN 55323-0066 Date received: /O / ' Street Address: Received by. 275Kelley Parkway Pian review fee- Orono. Main: 952-249.4600 Fax 952-249-4616 www.ci.orono.55356 Total Fee: mn.us �P This application fiorm must be completed in full and all required information must be submitted. GENERAL INFORMATION: Incomplete aPplications will be returned, (Please print) Job site Address: Jos'! ,•3 Will this be a Parade of Homes,Remodelem Showcase Home or other Display a special evNon'ees . Y !f yea, ent Permit is required with Police Deparhnent and City Counc7 approval 60 days prior to the event Shuttle bus service wY7 be required unless applicant demnstrates sufhclent or,-j&&paddng is available. Nbn-pemrifted events w&not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: _ State License# Expiration Date: Lead Certification Number. (for work on homes that were constructed prior to 1978 Expiration Date: Phone: GI - I/ (office) ;fe Mailing Address: rjr (cell) Contact Person: �~ r Cit�r ° ZIP: s^ v. Applicant is: Contractor / Homeowner tcrocie ones Email and/or Fax: 00, C° PROPERTY OWNER INFO A ON: Name: ; F9•�J Phone(day) Address: 0, Email and/or Fax city. ZIP PROJECT INFORMATION: Type of Project Any earth movement may require 0 Door(s) 0 Remodel 0 Water Damage MCWD review&permit 0 Window(s) 0 R airorm Minnehaha Creek Watershed District(MCWD) Damage 18202 Minnetonka Blvd 0 Sidin Q Restoration ❑Other. (specify) Deephaven, MN 55391 e-roof 0 Fire Damage Phone: 952-471-0590 Fax 952-471-0682 www.minnehahacreek aro Overall Project Description: „rt 2 ,, Estimated Construction Valuation of Proeec (excluding land) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide ail information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of hisiher knowledge. The applicant recognizes that they are solely responsible for submitting a complete appf"mbon being aware that upon failure to do$o, the staff has no alternative but to reject rt ur Ul it is complete; confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the • Some or all of the information that you are asked to provide on this application is classified by State law as either private or data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies ulnad taw. if ou refuse to s i ,theApplication may not be issued. Applicants Signature: � Dat. Last Updated- 03-01-2011