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� <br /> , City of Orono <br /> , Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> � Mailing Address: Permit number: <br /> // � PO Box 66 <br /> ,� <br /> , � ��, <br /> /� Crystal Bay, MN 55323-0066 Date received: <br /> I' O e^il\� O\\�` <br /> � �a� . II <br /> �� �� � �, a ! StreetAddress: Received by: <br /> ��' '�� ��,'�'u�,^� �! 2750 Kelle Parkwa <br /> � Y Y Plan review fee: <br /> \LRitE�H~���' 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 prinf) <br /> GENERAL WFORMATION: ` � <br /> Job Site Address: �� �-Y� � � � � �'✓� �vi� �.�v.�IG; S'�� " <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> /f yes, a special event permrt is required with Police Depar7ment and City Counci/approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is avarlable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI�`N�T INFORMATION: <br /> Name: ��`�yH f U!.l�.'J� <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: Cit : ZIP <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATIO . <br /> Name: ,.----� � f3,'1�-»� <br /> Phone (day): IL �.`• : --- U� <br /> Address: ;,� ' u� 4�G�1 '�C)� .,/� � Cit : ��r�/�1� ZIP: ��� � � <br /> Email and/or Fax ��„�,� f�-� p ,�r��.� _ �c,.,,,,� <br /> / _ __ ___ <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodef ❑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 /> e-roof � ❑ Fire Damage � www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ � C� <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 annu date our records and records of other governmental agencies <br /> re uired b law. If ou ref o I the information,th lication ma not be issued. <br /> � f� .. <br /> �"r <br /> ApplicanYs Signature: �,�1"��� � "� Date: ��T � <br /> _ �� <br /> Last Updated: 05-04-2009 <br />