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City of Orono <br /> 404.- / <br /> 7 <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: p7 Jb -00(y' <br /> ---:;(--:(LCC) <br /> r Box 66 <br /> o O Crystal Bay, MN 55323-0066 Date received: /�/ <br /> " ',•"' Received by: <br /> A �''` , ;,? p, Street Address: <br /> �� ! .� ,I Gtiti 2750 Kelley Parkway Plan review fee: <br /> t9kE8Sd4� Orono, MN 55356 <br /> Total Fee: /'ll./.K 06 <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: /9C6 e4) ,l /62 / /v ; <br /> _ 55.55 <br /> Will this be a Parade of Homes, Remodel rs Showcase Home or �` �;er Display Home? 7 Yes 2'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: r .G[ .0iLLd r-5' /i4c= - <br /> State License# ,3761a .33&7 Expiration Date: _5/3/1, I <br /> Phone: 65/ - 353 .h'cfq 02 (office) (cell) <br /> Mailing Address: >v„G E' mi..? _,,, ../.. City: zi K7,15.--.e. 5 <br /> . ZIP: 6 _-;// <br /> Contact Person: 06.1.2./ /6 /1-/y .:...„-/-4-1 Applicant is: ntra o Homeowner (Circle One) <br /> Email and/or Fax: 7�,3- --"/e,„- 'ysGG <br /> PROPERTY OWNER INFORMATIO • / <br /> Name: 5Z A / �� <br /> 4„,- �j15 <br /> Phone (day): 95-V_ 7'7 - aaa 7 <br /> Address: /pob -s'h ( City:,e_.4-ii� ZIP: 55356 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) E Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair @'Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> E Siding j2rRestoration ❑ Other: (specify) Phone: 952-471-0590 <br /> - Fax: 952-471-0682 <br /> ZRe-roof ❑ Fire Damage www.minnehahacreek.org <br /> erall Project Description: — c— P <br /> Estimated Construction Valuation of Project(eei'uding land) $ v `7/ 6)(. 0 <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 t e information,the application may not be issued. <br /> Applicant's Si / Date:Signature:9 / //-&' /jj <br /> Last Updated: 05-04-2009 <br />