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City of Orono <br /> BuildingPermit Application for Internal Work <br /> pp <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> 0 PO Box 66 Permit number: <br /> 0 0 Crystal Bay, MN 55323-0066 Date received: <br /> Received b <br /> ,� � a `�►^� ` Street Address: y' <br /> 2750 Kelley Parkway Plan review ee: <br /> t9kESH0 Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us / �J <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: Z-0 L %J- 7 d(Lc» <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 will e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Lac, ► S �f fc <br /> State License# Z031 _SSS Expiration Date: n►hi2__4( 3/ `i Z. <br /> Phone: Z - office 6i -_2_Z'SS 3 cell <br /> Mailing Address: /T0 Cit : t" A,-%,j-kA ZIP: <br /> Contact Person: &tjnWJ- S Applicant is: Contracto / Homeowner (circle one) <br /> Email and/or Fax: c _ J(,,Z <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): . Z Z - - 4 i <br /> Address: �2 3 14_1 I ,�/L�n�7 City: �ct� ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review& permits <br /> ❑ Door(s) XRemodel ❑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.M <br /> Overall Project Description: M in,ot; c skae-trod or-&-t <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 supplyffie information,the application may not be issued. <br /> Applicant's Signature. - -.� �/ Date: / G- <br /> Last Updated: 05-04-2009 <br />