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Cit of Orono o � <br /> . Y . . C ���ql� <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: ; <br /> O�,i,�,�0 PO Box 66 <br /> Permit number: ;� �C' /G'�7 7 <br /> � <br /> Crystal Bay, MN 55323-0066 Date received: �� ,� /C? <br /> ,� ������� <br /> ''� 's;-rz"� �, Street Address: Received by: <br /> �'�, �'� '�r ti 2750 Kelle Parkwa <br /> o Y Y Plan review fee: <br /> rqkESHO�'� Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: �� , 3 � <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: i�' <br /> Job Site Address: ,�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 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: G'�'y� �^ ,:� :�d_ <br /> State License# �;��: 3� � �� Expiration Date: " j ,Z v i <br /> Phone: S's� Lj�' �'�c � / office � cell <br /> Mailing Address: �3� /;� _ .��:s���� ��/%�' City: i ��_,�. z.,�..��,. ZIP: �,���.�. /, <br /> Contact Person: A plicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ���-/�,L�;y�,�;-�����-�/ �`r-- <br /> PROPERTY OWNER INFORMATION: � _ <br /> Name: �=. y,,� ,� � ���r�� i /�;,�-i �' <br /> Phone (day): � � � r .._� <br /> Address: 3��"��: `�-,�c� �l Cit : ��%���;�_ ZIP:�,��,�,� <br /> Email and/or Fax <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.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ /���;J , �u <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 ca e given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is ta�rinually up te our ecords and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information, the a 1i�atfon ma nottfe`Ssued. <br /> �,.% <br /> Applicant's Signature: =.i� �'.- - - --f3ate: /� -' .� -' /c� <br /> ��� <br /> LastUpdated: 05-04-2009 <br />