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j 4 � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �0 -'��� <br /> O.g,o,�.O Po sox ss <br /> Crystal Bay, MN 5532�0066 Date received: / IJ <br /> '"s, <br /> � ��;- Received by: <br /> a � �� �. Street Address: <br /> �',F, ° ^� �ti�' 2750 Kelley Parkway Plan review fee: <br /> l��Hogw 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 print) <br /> GENERAL INFORMATION: <br /> Job Site Address: _��(v ��.-�?I„�y ��^�-C�S-� ��_ <br /> Will this be a Parade of Homes, Remod lers Showcase Home or other Display Home? Yes o <br /> !i yes,a special event pe►mft is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required uNess applicant demonstrates sufficier►t on-site parlcing is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP.pLICANT INFORMATION: <br /> Name: Fif i-{-� �-�i'� �'(� <br /> State License# ���G��'j ���.(.�. Expiration Date: 7i°`3�/ZDi Z <br /> Phone: b� - �,'�-`L �j o�ce � -�{'7� -�� cell <br /> Mailing Address: �p� (! U � r, Ci : � � ZIP: � <br /> Contact Person: „_ � Applicant is: Contrac r / Homeowner (Clrcle One) <br /> Emai�and/or Fax: tw U �, -Q i-f-.�.P_,��?�, �r S.C.C,S S �-�(� , - �i7 <br /> PROPERTY OWNER INFORMATION: <br /> Name: (�-�{i•._ 1 SY6 v�W�W'�� <br /> Phone(daY): `�SZ--i-(7�-t-{L>��� <br /> Address: �2-10 ��i..��i� (��j,�� ; r, CitY:ja(.)G�,b7,�t��� ZIP: �5�� t <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: (speciy) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> �roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: ; '�� ,�. ..�- ��p <br /> Estimated Construction Valuation of Project(excluding land) $ j,�(�,'�n., �) <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 altemative <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 Gassified 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 informatio� which generafly cannot be given to either the 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 governmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: 7 ? lV <br /> Last Updated: 05-04-2009 <br />