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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> t Mailing Address: <br /> Og,0 PO Box 66 Permit number: <br /> 4-11 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <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: /00 .) Do- <br /> Will this be a Parade of Homes, R modelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f 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 <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I FORMATV1.124Jr� <br /> : _ <br /> Name: d l M12 R&0 1- l l <br /> State License# Expiration Date: — zv <br /> Phone: 7,5rl- 7 G office cell <br /> Mailing Address: / �,' 4- N VJ Ci. "P%��T ZIP: <br /> Contact Person: q L, Applicant is:( Contrtor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: �+ <br /> Name: <br /> Phone (day): - 3 - <br /> Address: �l0© ,�iJ� k�oAn City: ,l'I p�.� � r- ZIP, 3L-;'3 Y <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑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 /> e-roof ❑ Fire Damage www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ <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 i ormation,the application may not be issued. <br /> Applicant's Signature: Date: <br /> Last Updated: 05-04-2009 <br />