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kun-- b -w- <br /> 13aq - H14 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> windows, doors, siding, re-roof, etc. <br /> Mailing Address: <br /> 0A�', Permit number. <br /> etaI <br /> rPO�\ C 66 <br /> rysSay,MN 55323-0066 Date received: f0 O <br /> C a Street Address. Received by. <br /> G 2750 Kelley Parkway Plan review fee: <br /> ®iy Orono,MN 55356 y� <br /> ."� 8�...-ter-• Tote/Fog: 7 <br /> Main: 952-249.4600 Fax: 952-2494616 www.d.orono.mmus <br /> This application form must be completed in full and all required Information must be submitted. <br /> Ineomplate applications will be returned. (Please print) <br /> GENERAL INFORMATION.LO <br /> Job Site Address: U���rimn eaa� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes MNo <br /> if ym a special event permit is r+epuired with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless sppikent demonstrates su/fklant on-alta parking Is avellable. Non-pemdtted everts will not be allowed. <br /> CONTRACTOR/APFLICANT INFQORRMATTQN. <br /> Name: A n (__o n f-41D to <br /> State License# Expiration Date: <br /> Phone: -rI MI <br /> office call <br /> Mailing Address: Gi ZIP: <br /> Contact Person: V► Applicant is: ntractor Homeowner x cteooel <br /> Email and/or Fax: I <br /> PROPERTY OWNS INFO MATIO <br /> Name: c r i <br /> Phone(day): - Q <br /> Address: W R Ci ZIP: 3 <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 /> Minnshaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repay ❑Stam Damage 18202 Minnetonka Blvd <br /> Oeephaven,MN 55391 <br /> ❑Siding ❑Restoratlon ,❑Other.(specify) - - Phone: 952471-0590 <br /> Fax: 952471-0682 <br /> Re-roof ❑Fire Damage www.minnehahecreek.oro <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ 6!j oo a <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 lnfotmation is to annually update our records and records of other governmental agencies <br /> required by law. K you refuse to sup` the information,the apiftilon may not be issued. <br /> 4Z�/i�V <br /> Applicant's Signature: Data: TU <br /> Last updated: 05-04.2009 <br />