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City of Orono `a� (iv <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) 5a*.75 <br /> Mailing Address: Permit number: O D^LSO <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: /�Zo /D <br /> Received by: 411 <br /> Street Address: 2 <br /> 2750 Kelley Parkway <br /> Orono, MN 55356 Plan review fee: �• cJ <br /> L9gE$Hog�' 41 <br /> yTotal 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: ���w <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 INFORMATION: <br /> Name: to P P e _ p Z J" ( L <br /> State License# A00 5.& `?o U Expiration Date: O it <br /> Phone: &I A - 3 c,'i3 0 W Ye(office) Fj (cell) <br /> S � <br /> Mailing Address: °-,-1P"A' L -1- /: City: ZIP: <br /> Contact Person: jvt i kr- 59-k0 4---ave' Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: Z.o x 9 S'!-- Y7 Y_ S f <br /> PROPERTY OWNER INFORMATION: ff <br /> Name: i�%��t: 4- 5he`.t-1 �.1a.pti, <br /> Phone (day): L-/'7 5 — T3 f <br /> Address: City: CV10 A d ZIP: j,�- 3 SG <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: h�^5;.+� 5crct f,5Lc'�> JAny 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 /> 5a Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-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 information,the application may not be issued. <br /> Applicant's Signature: �� Date: <br /> Last Updated: 05-04-2009 <br />