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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) 2 <br /> Mailing Address: Permit number: cc,/U- C0 305 <br /> �j,� PO Box 66 <br /> O O Crystal Bay, MN 55323-0066 Date received: 577,3/ <br /> b <br /> � � I Street Address: Receivedy' <br /> ;1".` o 2750 Kelley Parkway Plan review fee: /A <br /> 'kEsso4` Orono, MN 55356 / <br /> Total Fee: e_ <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us C(/ v 1 <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: f/ . 5- /4) <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 1No <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: U f ., T- ._- <br /> State License# Expiration Date: if <br /> Phone: r �_ 5._ 13 (office) (cell) <br /> Mailing Address: •0. L • _ Cit : - ZIP: 5'6 3 .3- 7 <br /> Contact Person: Applicant is: ontractor Homeowner (Circle One) <br /> Email and/or Fax: re , t D: 766,)_ . <br /> PROPERTY OWNER INFORMATION: <br /> Name: ( �,'��,'c.,.., `>?Sle';14e <br /> Phone (day): _ lye i <br /> Address: ��' City: 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) f -r Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage ((1 in.iNAA:Ykizti f www.minnehahacreek.orq <br /> Overall Project Description: ei h;,,; ck h g., <br /> Estimated Construction Valuation of Project(excluding land) $ f 7 76 00 <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: �, gine. Date: <br /> Last Updated: 05-04-2009 <br />