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t <br /> � ti <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> �,�,�. PO Box 66 Permit number: p���0" <br /> � 0 <br /> Crystal Bay, MN 55323-0066 Date received: —�� <br /> a �t�� �, Street Address: Received by: <br /> �'�,c,L '� �v� ��ti 2750 Kelley Parkway Plan review fee: <br /> �kESH��`' 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: 3Z� �v � /�d� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> lf 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/AP LI NT INFORMATION: <br /> Name: � �� r�1,C', <br /> State License# Z ' Expiration Date: zo�� <br /> Phone: -5'S o •- office cell <br /> Mailing Address: - Cit : i� z�ze ZIP: S' 7 <br /> Contact Person: �o n �" Applicant is: Contractor Homeowner (CircleOne) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: .Sr�E✓e�z �' -Svsv�, Glli�S�vt <br /> Phone (day): �' - - <br /> Address: ��S �. .�,3�o,,u�, � City: �i�s�p ZIP: S`S'3S(�� <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 /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.or <br /> verall Project Description: � �_ � r� / �F � �''PL v- �j,n .�o� <br /> Estimated Construction Valuation of Project(excluding land) $ Zq �/,p p <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 t <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 /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: /�����O <br /> Last Updated: 05-04-2009 <br />