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" # l3 I I Coo City of Orono Building Permit Application for Internal Work windows, doors, siding, re-roof, etc.) iblall�PO�6� OPermn+b Permit nuer: SOI o- 069/ Crystal Bay.MN 553234066 Date received: � Sheet Address: Received by: G 2750 Kelley Parkway Plan review fee: � Qss' Orono,MN 55356 Main: 952-249-4600 Fax: V52-249-4618 www.morono.mn,us Total Fee: This application form must be completed in full and all required information must be submitted. GENERAL INFORMATION Incomplete applications will be returned. (Please print) Job Site Address: Lklion Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No Ny",a spedal event permit is required with Police Depanowfif and City Coundl approve/60 days prfor to the event. ShWW bus service w9 be required unless applicant demonstrates si liraant on slle peMkV is available, Non-parmftd events Wfil net be aknVed. CONTRACTOR/A LICANT INFORMATION: Name: tt State Lioense# Expiration pate: Phone: - Ot�O ffice cell Mailing Address: CI ZIP: Contact Person: Applicant is: Contractor / Homeowner (c&do am) Email and/or Fax: PROPERTY OWN NFO MATION: .( Name: J . Phone(day): Cksa 165-1 Address: ci zIP: Jr 5 l Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may roquire MCWD review&permits 13Door(s) E3 Rona" ❑Water Damage Minnehahs Creek Watershed District(MCWD) ❑wkx"$) ❑Repair ❑storm Damage 19202 Minnetonka Blvd MN 55391 L]Siding ❑Restoration [I Other(specify) Photo: 952.471-0590 Fax: 952.471-0682 LJJ�R []Fire Damage www.minnehahacreek.orn Overall Project Description: -1T . Estimated Construction Valuation of Pilblect(excluding 1 d) APPLICANT ACKNOWLEOGOMENT: • Agrees to provide all information required or requested by the Building Department • Certifies Out the information supplied Is true and corned to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to reject it until it is complete: • Some or all of Ho Informetlen that you are asked to provide on this application Is classified by Biala low as either private or confidential. Private data is.information which generally cannot be ghren to the public but can be given to the subject of the date. Confidential data Is lidorrnadon which generally cannot be OWM to either the public or fine subject of the data. Our purpose and Intended use of this inWmadon Is th annually update our records and records of other governmental agencies required by law. If you refuse kLsopply the Whanedon.the application may not be issued. Applicant's Signature: Last Updated: 05.04-2009