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ft City of Orono if Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: .¢,�,�0 PO Box 66 O Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: �F, Gtiti 2750 Kelley Parkway Plan review fee: l9xx0¢� Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 214o 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: WA L,V-(,-- /2�oFl�yy State License# q Z Z q Expiration Date: 3 3 r Phone: (0 5-1- Z 51- 01110 office cell Mailing Address: Z Z-7 C-410.a Ci J6'4 v` ZIP: ,41ti' / Contact Person: 4Y LL� Applicant is: ontra o / Homeowner (circle one) Email and/or Fax: kgyT nn ® LWrt I ker`oy-Cin q, Gc U-T/-05-1- 0916, IJ V PROPERTY OWNER INFORMATION: Name: _ X11 w6 ,DY6►� Phone (day): l Z- -337- 585 5 Address: Y// S� Gy.a�,2Towti 90 City: O2�-vim ZIP: 5-37 3 Sy Email and/or Fax PROJECT INFORMATION: Zk Type of Project: Any earth movement may require MCWD review&permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 Fax: 952471-0682 Re-roof ❑ Fire Damage www.minnehahgoik.org Overall Project Description: RAO-- 664' t Estimated Construction Valuation of Project(excluding land) $ 77, UOO APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct 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 the information that you are asked to protide this application is classified by State law as either private or confidential. Private data is information which generally t be given to the public but can be given to the subject of the data. Confidential data is information which generall n t be given to either the public or the subject of the data. Our purpose and intended use of this information is t nnuall update our records and records of other governmental agencies required b law. If you refuse to su f ation th lication may not be issued. Applicant's Signature: Date: U / Last Updated: 05-04-2009