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, . • City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: l l- (�U a�/ O.��,�0 PO Box 66 Crystal Bay,MN 55323-0066 Date received: J�"l'� / � � Street Address: Received by: 2750 Kelley ParkwaY Plan review fee: �� Orono,MN 55356 Total Fee: �3 j ,� Main: 952-249-4600 Fax: 952-249-d616 www.ci.orono.mn.us This applicatlon form must be completed in full and all required information must be submitted. Incomplete applications wfll be retumed. (Please print) GENERAL INFORMATION: � � Job Ske IWdross: ��„�� ;�JC�L'�t'��!� ��` WIII this be a Parads of Homes, Remodelers Showcass Home or other Display Home? Yes No H yss,a speda/e►rerN pemiit!s required wlth Pdke Depertment and C1ty Coundl epprova/60 days prior to the event Shud/e bus service will be requlred uNess a�pplkant dertansbstes s�dBdent on�clte peAcing!s ave11a61e. Non-pennitted events wYl not be a0owed. CONTRACTOR/APPUCANT INFORMATION: Name: /�1��(✓l5�'- �oOF� ��i l�✓�'�IdO(� Li►� State License# ;Z p p/p a 7 7 Expiration Date: �3/3/ � p�a Lead Certfication Number: Expiration Date: (for wnrk on homss that wsro construc�prlor to 1978 Phone: 7f�3—�/a� 7'9('9�v (office) 76 3 o�gO— /.3� � (celp Mailing Address: $'/ �-,,pr� f* City: Qp�e �� ZIP: s3 (q Contact Person: /�pnn.f� �fiS6•� Applicant is: n or / Homeowner �c�.o�.� Email and/or Fax: ')63 — y �7� jp0� PROPERTY OWNER INFORMATION: Name: Phone(day): Address: -7 S_� ��K,,t e�� :��/� City:��L�k� ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movemsnt may require ❑Door(s) ❑Remodel ❑Water Damage MCWD roview 3 psrmits: Minnehaha Creek Watershed DisVict(MCWD) ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑Restoratio� ❑pther:(spec;ify) Deephaven,MN 55391 Phone: 952-471-0590 �Re-roof ❑Fire Damage Fax: 952-471-0682 www.minnehahacreek.orQ Overall Project Description: Estimated Conatruction Valuatbn of Project(excluding land) S `c� APPLICANT ACKNOWLEDGEMENT: Agrees to provide all infom�ation required or requested by the Building Department; Certifies that the infortnation supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely respo�sible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it uMil it is complete; � Some or all of the information that you are asked W provide on this application is dassified by State law as either private or confidential. Private data is infom�ation which generally cannot be given to the public but can be given to the subject of the data. Confldentlal data is infoRnatbn which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this infortnation is to annually update our records and records of other govemmental agencies uired b law. If u refuse to su rtnation the a icabon ma not be issued. ApplicanYs Signature: l/� Date: s � �='�I Last Updated: 03-01-2011