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' ` City of Orono �oa <br /> 3 � <br /> Building Permit Application <br /> Mailing Address: �� <br /> �\ PO Box 66 Permit number: — <br /> �Q �� �� Crystal Bay, MN 55323-0066 Date received: ��' <br /> �'`��.�;. � <br /> ,� t�'���1R��;,� a � Street Address: Received by: �{ <br /> �',�, �� '�"° G� � 2750 Kelley Parkway Plan review fee: <br /> L9kESH04'� Orono, MN 55356 <br /> Total Fee: 3a�• 3� <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: ���� ��. Z � 5 �2v� � <br /> Will this be a Parade of Homes, Remodelers Showcase H me or other Display Home? ❑ Yes O;.�lo <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 w�i!'be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP CA T INFORMATION: . � <br /> Name: - <br /> State License# (� Z Expiration Date: <br /> Phone: � Z7� (office cell <br /> Mailing Address: UOQDUL C— Cit : j,� ZIP: <br /> Contact Person: �„� Applicant is: ontractor Homeowner �c���ie o�e> <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORM TION: ; <br /> Name: � � �- � , �-��ll�C <br /> Phone (day): �� — � 0 / <br /> Address: 'f-,j � Z L�K.� Cit : (�I/ ��{- ZIP: ��� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&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.orp <br /> Overall Project Description: �� �j i� '�CISTfI� "��t)'i �(l� 15�� <br /> Estimated Construction Valuation of Project(excluding land) $ �d , ��-� <br /> APPLICANT 8� OWNER ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department, <br /> • Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize <br /> that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff <br /> has no alternative but to reject it until it is complete. <br /> . The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by <br /> City Staff, consultants or agents, for purposes of investigation of this request. <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 whi generally c e given to either the public or the subject of the data. Our <br /> purpose and intended use of this ' m i i a u date our records and records of other governmental agencies <br /> re uired b law. If ou refus o su I e orm t' ,t a lication ma not be issued. <br /> Applicant's Signature: Date: ��j � � <br /> Owner's Signature: Date: <br />