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� City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: ��/d — D0s9ot.• <br /> 4v�,� PO Box 66 <br /> � � � Crystal Bay, MN 55323-0066 Date received: 7�/Lo U <br /> �"•"'m'" Received b 2 <br /> a ��w�a�� �, Street Address: y� • <br /> �'� ' �� Gtii4 2750 Kelley Parkway Plan review fee: <br /> ��kESKo�� Orono, MN 55356 <br /> Total Fee: t5 �(� (�� <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. (P/ease print) <br /> GENERAL INFORMATION: " �� / <br /> Job Site Address: � �� ��l �-�/`�hc <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <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 will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI T INFOR ATIO : ('� • <br /> Name: ►-, ' J`l-r �, ��h j � �- <br /> State License# 5� - Expiration Date: il1 `/� <br /> Phone: -. � office � r cell <br />� Mailing Address: � Z=" ,",,.� Cit : ' Z : � <br /> Contact Person: Applicant is: actor / Homeowner (Circle One) <br /> Email andbr Fax: � �r �'it[�u0 c%n /����C��� <br /> PRQPERTY OWNER INFORMATION: , ' / <br /> Name: / �" /'1r{� .jc��-, <br />� Phone (day): - .- � -- � <br /> Address: ' pB'Z ttiv/pcy D�^!v Cit : �i�Gt ZIP: � 5��0 <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: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.min hahacreek.or <br /> Overall Project Description: L� ��� <br /> Estimated Construction Valuation of roj t( cluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: �`'��� <br /> � � ,f� f'`�-�e� .�l�r-� �S c3,r-��;.-,�c l�, <br /> • Agrees to provide all information required or requested by the Building Department; � <br /> 7�"' re�c°PSS ��%/y'��" <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recogni�.'es that they <br />� are solely 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 provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally can be given to the public but can be given to the subject of the <br /> data. Confidential data is in a i which generally cann be given to either the public or the subject of the data. Our <br />� purpose and intended use this inf mation is to annuall update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su the informat' n, th a lication ma not be issued. <br /> F <br /> ApplicanYs Signature: Date: ������ <br /> Last Updated: 05-04-2009 <br />