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City of Orono Building Permit Application for Internal Work �'�� � (windows, doors, siding, re-roof, etc.) Ma111ng Address: Permit number: a0/�j—DO�j'r(� O�Q 1��O PO Box 66 `w Crystal Bay, MN 55323-0066 Date received: . a StieetAddress: Received by: ��, ' Gti 2750 Kelley Parkway Plan review fee: l *a Orono, MN 55356 9x�o4. Total Fee: �g�� Main: 952-249-0600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATIO� !' � J L�Y��T�� cJ� / Job Site Address: � ' Will this be a Parade of Homes, Remod lers Showcase Home or other Display Home? Yes No ff yes,a specia!event permit is raquired with Police Department and City Councif approval 60 days prior to the event. Shu(tle bus service will be required unless applicant demonstrates sufficrent on-sife parking is available. Non-pe�mitted events wf11 not be allowed. CONTRACTOR I APPLICANT INFORMATION: Name: t� State License# Expiration Date: Phone: G' — office cell Mailing Address: Cit � ZIP: , Contact Person: � Applicant is: ontractor Homeowner (Circle One) Email andlor Fax: PROPERTY OWNE NF RMATIO : Name: � s� Phone(day): ' -- Ci : ZIP: Add ress: ' Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review 8 permits ❑ Door(s) ❑ Remodel ❑Water Dam'age Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd . Deephaven, MN 55391 ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952�71-0590 Fax: 952-471-0682 �roof ❑ Fire Damage www minnehahacreek.orq Overafl Praject Description: D�" r � Estimated Construction Valuation of Project(exctuding land) $ APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building D'epartment; • Certifies that the information supplied is true and cocrect to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this applicafion is classified by State law as either private or confidentlal. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subJect of the data. Our purpose and intended use of this information is to annually update oUr records and records of other governmental age�cies re uired b law. If ou refuse to su I the inf�rmatio the a licaticin ma not be issued. Applicant's Signature: Date; � �� Last Updated: 05-D42009 Z 'd SLO++S9SiS9T ��I �liempe� e{,S � T T OT 9i daS