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i - r City of Orono �� J` Buiiding Permit Appiication for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: _. �J � / Og,�,�.0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: � ,� 9 �-�'' �, Street Address: Received by: ��',�c, ' �� titi 2750 Kelley Parkway Plan review fee: L�ESHO�`� Orono, MN 55356 Total Fee: �l�J-�, �� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This appfication form must be completed in full and all required information must be submitted. Incomplete apptications will be returned. (Please print) GENERAL INFORMATION: ) Job Site Address: � `�� )C�t�`� ,�� ct Will this be a Parade of Homes, Remodelers Showcase Home or other Dispfay Home? ❑ Yes No !f yes, a special event permit is required with Police Department and City Counci/approval 60 days prror to the event. Shuttle bus s rvice will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR 1 APPLICANT INFORMATION: Name: `� f1 CG��r;L �.c�}�y''jp!'��i ��C State License# �v��;,�� Expiration Date: / =5 Lead Certification Number: Expiration Date: (for work on homes that were constructed rior to 1978 ,� Phone: �S; - ��-�C G�S (office) U ,J-� --5�� S' `r� 7 7 (cel�) Mailing Address: ��?_;" �'>. ^ � � ,�'j v� � - City: � �a�y,,'x� ZIP: �--�3 5 I Contact Person: _ y) Applicant is: � Co� ntracto / Homeowner (Circte Onej Email and/or Fax: ��.;� - y �� - / 7�� PROPERTY OWNER IN O MATtON: Name: y �� l�'�� Phone (day): ��7�-- �� " Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review& permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Siding ❑ Restoration ❑ Other: (specify) i Deephaven, MN 55391 Phone: 952-471-0590 [�Re-roof ❑ Fire Damage Fax: 952-471-0682 �� www.minnehahacreek.orq Ovecall Project Description: •-�-cZ�,.� � �,� ,� !� �;�,. Estimated Construction Valuation of Project(excluding land) $ _�yG�� — APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete appfication being aware that upon failure to do so, the staff has no alternafive but to reject it until it is complete; • Some or all of the informafion that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidenfial data is informatio which nerally cannot be given to either the public or the subject of the data. Our purpose and intended use of this inf rmation�i to annu�( y update our records and records of other governmental agencies re uired b law. If ou refus o su I the infb mafion, a fication ma not be issued. � App(icanYs Signature: r Date: � �" �� �� Last Updated: 03-01-2011