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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: <br /> O�,ok. PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> 40' - Received by: <br /> A vitw'lt Street Address: <br /> 1.t4 .Ai 41 Gtiti 2750 Kelley Parkway Plan review fee: <br /> �� Orono, MN 55356 <br /> Total 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: /Y1/9 /OM Il,� V�� . <br /> Will this be a Parade of Homes, Remodelers howcase 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: wC.1/J6Z rce .E /,C..i4 o v <br /> State License# ,;26(s) 3 3 828-7 Expiration Date: 5/3 / l/L <br /> Phone: /- 35 3- 5 L/ (office) (cell) <br /> Mailing Address: D,9 E . -, _ Zc Cit : - / ypv'ZIP: "---r----- <br /> Contact Person: /---e517/pi , /� 67/ 7�„L.,4,-7 Applicant is: Contracts' / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: . -�y'/7 /N " v i <br /> Phone (day): ; — 9 — aG <br /> Address: 4-l-/'7 j 'Li-- q I_7 <br /> Dckd City: ();%/'t-C) ZIP: 55 <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 /> Re Fax: 952-471-0682 <br /> roof <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: pae_..4,- U t r-_e_4-66 7 <br /> Estimated Construction Valuation of Project excl ing land) $ � <br /> , e)e <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, t application may not be issued. <br /> Applicant's Signature: 717, i Date: ��) Sy,' <br /> 1 ,>e/lj <br /> Last Updated: 05-04-2009 <br />