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City of Orono <br /> Building Permit Application <br /> Mailing Address: Permit number: <br /> Og,0�O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> r' EsE10 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: <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 be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFO WE)�UL04c5—\ -T- <br /> State <br /> TION: <br /> Name: (LtZ�License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: <br /> Contact Person: Applicant is: Contractor omeo ner (Circle One) <br /> Email and/or Fax: _ q <br /> PROPERTY OWNER INFORMATION: y <br /> Name: �iE(LiZw Lr) F/L✓4OTI— <br /> Phone (day): (Q j Z. - l -S2 _ <br /> Address: _l�Z l4c�T ,� 5 PO <br /> '15 <br /> �n r� City:011_0& ZIP: j 3� <br /> Email and/or Fax -A 4 yt4(_ VL141-,-W yb4 ) 460 , C._,CD UA <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 El Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration Other: (specify)nOrr' Phone: 952-471-0590 <br /> ( � �Z � Fax: 952-471-0682 <br /> El Re-roof El Fire Damage c,�J�G' www.minnehahacreek.o <br /> Overall Project Description: <br /> Estimated Construction Val ation of Project(excluding land) <br /> APPLICANT & OWNER ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department, <br /> • Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize <br /> that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff <br /> has no alternative but to reject it until it is complete. <br /> • The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by <br /> City Staff, consultants or agents, for purposes of investigation of this request. <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 b"ven 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 informa,i armuay update our records and records of other governmental agencies <br /> required by law. If you refuse to sup o "1he application may not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: --_:`= �. 0 Date: 9 <br />