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� � <br /> -- City of Orono (� I� � �ss P <br /> _._._-----. <br /> • Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailin Address: <br /> ��� PO Box 66 Permit number: <br /> �/�� ���\ Crystal Bay, MN 55323-0066 Date received: <br /> �,a ��,��,.:;� a,�! Street Address: Received by: <br /> �'�n �'� ��,r �' ' 2750 Kelle Parkwa <br /> t ,� ��/ Y Y Plan review fee: <br /> '�gESH�% 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: � �1 � ���_ ` <br /> Job Site Address: /) "" � �'� -� , 1 j <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will b <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI NT FORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office cel�_ <br /> Mailing Address: % Cit : ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email andlor Fax: <br /> PROPERTY OWNE�C INFOR ATIQ�tI: <br /> Name: "-� <br /> Phone (day): C " - - � <br /> Address: Cit : . � ' _ ZIP: � �.�'� <br /> Email and/or Fax - � � � � r' <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8� 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.min ehahacreek.or <br /> Overall Project Description: �� <br /> Estimated Construction Vafuation of Project(excluding land) $ �(;T�;G <br /> APPLICANT ACKNOWLEDGEMENT: � <br /> • Agrees to provide alf 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 /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued. <br /> - } ' <br /> ApplicanYs Signature: Date: ✓� (�� ^ <br /> Last Updated: 05-0�-2009 � <br />