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Aug. 19. 2010 5: 05PM No, 5555 P, 2 <br /> , <br /> � � City of Orono 1� .��,0 <br /> Building Permit Application for In�ernal Work ��� <br /> �windows, doors, siding, re-roof, etc.) <br /> Mailing Addre ss �' �;� �:- --�,t -/ <br /> O�,l,�,�0 PO Box 66 Permit number. y -- <br /> Crystal Say, MN 55323-0066 Date received: `>/ z�` //c <br /> StreetAddress: Received by: �-(.�. �: /�''i= <br /> ��, � 2750 Kelley Parkway Plan review fee: <br /> ��g�o�4� Orono, MN 55356 <br /> Total Fee:�3�/�� 2� <br /> Ma(n: 952-249�4600 Fax: 952-249-4616 www.ci.orono.mn.us T �) <br /> This application form must be completed in full and a(I required information must be submitted. <br /> Incomplete epplications will be returned, (Plesse print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ' C. ' ' 0�.�, �.� <br /> Will this be a Parade of Homes, Remodelers Showcase Home vr othe� Display Home? Yes o <br /> 1/yes,a spec/al event peimltls requlred with Po/ice Department and City Counci/epprbva!60 days p�o�to the avent. ShufHe bus servlce will be <br /> �quired unless applicenf demonsErefes suff/clenf on-site parking is available, Non-pe►mitted events will not be alloWed. <br /> CONTRACTOR/AP LICANT IN�ORMATION: <br /> Name: a �� <br /> State License# � Expiration Date: "� • <br /> Phone: - office cell <br /> Mailing Address: ` v Cit : ' ZIP: <br /> Contact Person: � � e.I1P ��� t�� Applicant is: ra or / Homeowner �c�r�ie o�a) <br /> Email and/or Fax: m ;r he►�� ;,,�,��o,� � .}-h (��il��? ► C p <br /> PROPERTY OWNER 1NFORMATION: <br /> Name; � <br /> Phone(day): a- <br /> Address: � ' �, Cit : 0. ZIP. <br /> Emai1 and/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: Any earth movement may require <br /> MCWD review&pe�rnits <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) Phona; 952-471-0590 <br /> Fax: 952-47'I-0682 <br /> ❑Re-roof []Fire Damage wuuw,minnehahecreek.ora <br /> Overall ProJect Description: ��a-�� 2�ylQ�e ti <br /> �stlmated Constructlon Valuation of Project(excluding land) $ � �, (�(� (� <br /> APPLICANT ACKfdOWI.�DGEMENT: <br /> • Agrees to provlde sll infnrmation required or requested by the Building Department; <br /> • Certifies that the inFormation supplled Is true and correct to the best of his/her knowledge, 7he applicant recognizes that fhey <br /> are sofely 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 provlde on this application is classified by State law as either privata or <br /> confidential. Private data Is inPormation which generally cannot be given to the public but can 6e given to the subject of the <br /> data. Confidential data Is InFormation which generally cannot be given to eithe� tha 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 govemmental agencies <br /> re uired b law. lf ou refuse su I the information,t lication ma not be issued. <br /> Applicant's Signature: � r bate: � / �J <br /> Last Updated: 05-04�2009 <br />