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� � � City ofi Orono Building Permit Application for internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: oZ l f -(' '��.�j_ �- PO Box 66 Q . � Crystal Bay, MN 55323-0066 Date received: � Z�j/ ' � � � �� y�` � StreetAddress: Received by: � �� 2750 Kelley Parkway Plan review fee: L�.xc�$Ho4`� Orono, MN 55356 � Tota! Fee: �� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be cornpleted in full and ali required informa�ion must be submitted Incompiete appiications will be returned. (P/ease print) GENERAL INFORMATION: Job Site Address: 4 f Will this be a Parade of Homes, Remodelers Showcase Home or other Dispiay Home? ❑ Ye ❑ No If yes,a specia/event permit is required with Police Department and City Counci!approva160 days prior to the event. 5huftle bus ervice witl be required unless applicant demonstrates su�cient on-site perking is availabie. Non-permitted events will not be allowe CONTRACTOR/.APP�LICANT INFORMATION: Name: �� /� �(�., ,o�s State License# ��g3,� Expiration Date: -�—��_, Phone: � office celi Mailing Address: _� vy5 fi ,v� Cit : ,� ZIP: � Contact Person: � e 1,,.4 �r Applicant i � n rac ! Nomeowner (Circle One) Email andlor Fax: �6 4i PROPERTY OWNER INFORMATION: Name: _� e c i Phone (dayj: / d 6�5, �l,� � Address: Cit : ZIP; Email and/or Fax PROJECT INFORMA�'ION: Type of Project: Any earth movement may quire ❑ Door(s) ❑ Remodel MCWD review 8�perm ❑Water Damage ❑Window(s} ❑ Repair ❑ Storm Damage Minnehaha18202 M nnet nka g�� ct(MCWD) ❑ Siding ❑ Restoration Deephaven,MN 5539 ❑ Other; (specify} Phone: 952-471-059 Re-roof Fax: 952-471-0682 ❑ Fire Damage www.minnehahacreek.o Overal! Project Descriptuon: Estimated Construction Valuation of Praject(excluding land) $ U APPUCANT ACKNOWLEDGEMENT: �-S �C� • Agrees to provide ali information required or requested by the Building Depart • Certifies that the informafion supplied is true and correct to the best of his/her knowledge. The applicant reco nizes that they are soiely responsibie for submitting a complete application being aware that upon failure to do so, the staff h no attemative but fo reject it until it is compiete; • Some or all of the information that you are asked to provide on this appiication is classified by State law as ither private or confidential. Private data is information which generaliy cannot be given to the public but can be given to th subject of the data. Confidential data is information which generally cannot be given to either the public or the subject o the data. Our purpose and intended use of this information is to nnuall update our records and records of other govern entai agencies required by(aw. If you refuse to s I he inf n,th a lication ma not be issued. ApplicanYs Signature: Date: �