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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) ,{ <br /> Mailing Address: Permit number: ?e%09.--6100 ,<--' <br /> g,0,� Cr Box 66 <br /> O O Crystal Bay, MN 55323-0066 Date received: /67°V . <br /> 0. Received by: <br /> i Street Address: <br /> ii19 Gti 2750 Kelley Parkway Plan review fee: <br /> t�gESHo4w Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us /�r/O/ <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: --7--/O-e) c?� j ;) /o- Ai(i( k-1 Gw-evv <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/APPLIQNT INFORMATION: <br /> Name: a�%vt=� _A 1 +-,_`_,6'4..J G.:..<, -7—' <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: t--L p-i <br /> Phone (day): (sz 1 Z <3g --- ((-t ' <br /> Address: —2467) 4)�/s,a,(--___ 4/...II 9 4 City: Cj,z,AO ZIP: `, <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 /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> .�g e Fax: 952-471-0682 <br /> " <br /> ;�' ~ roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $- /7--,5—Cei <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 informati•- which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of thH infor ation is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse . suppl the information, the application may not be issued. <br /> Applicant's Signature: Z- 1frV A. <br /> Date: 4) ..Z —G/ <br /> Last Updated: 05-04-2009 <br />