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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 /> a.i Cr Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> "4`s: Received by: <br /> a l', a, s Street Address: <br /> �. 1f ,. 6" 2750 Kelley Parkway <br /> Orono, MN 55356 Plan review fee: <br /> V;y • <br /> ygE <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: Crl 1)J E td1(\L)� Tittil- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [I 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: Minn ILSOTO—ELK <br /> State <br /> inn> tO—ENState License# .,2$77 Expiration Date: 3)31/ / <br /> Phone: --/(p13-3C J -3j 16 (office) (cell) <br /> Mailing Address: % c) n 1-Au3u Cit : ZIP: 553(01' <br /> Contact Person: Chrib-ire Asn s.,.J Applicant is: Contractor Homeowner (Circle One) <br /> Email and/or Fax: CLs cu..),) mrk0 X,f. Cr'✓v1 <br /> PROPERTY OWNS INFORMATION: <br /> Name: nl j a5 k IMCLn <br /> Phone (day): a-i112 n37 <br /> Address: 175 U.); lahv(-S)c--t-rofkA City: 0 rbil 0 ZIP: 55343g) <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 /> OWindow(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ji Siding ❑ Restoration ['Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ 301C;Cb..DO <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,the application may not be issued. <br /> Applicant's Signature: CirC w.i.) -- Date: \—\3`\(C) <br /> Last Updated: 05-04-2009 <br />