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, � ` City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> � Mailing Address: <br /> Permit number: <br /> �.,�,�� PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> I D O\`1� <br /> � y Received by: <br /> (a ��'�,�r-�:" �,��� Street Address: <br /> ��'�,n ��,��, ��ti� 2750 Kelley Parkway Plan review fee: <br /> L�kE3H 4'� 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: ��1'SO �� ���1�� <br /> Will this be a Parade of Homes, Remodelers S owcase Home or other Display Home? ❑ Yes No <br /> /f yes, a specia/event permrt is required with Po/ice Department and City Council approval 60 days prior to the event. Shuttle bus service wi/l be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: • wr � �d �, o� Wi w T <br /> State License# ���p�o� ��Z Expiration Date: � 3� /0 <br /> Phone: '�3 y�� ���6 (office) (cell) <br /> Mailing Address: �{S Cit : G � C', ZIP: <br /> Contact Person: �jY�k �„�zi�k Applicant is: on r c or / Homeowner (CircleOne) <br /> Email and/or Fax: _ �,3 ��� 9 pp j <br /> PROPERTY OWNER INFORMATION: <br /> Name: S7�r,v�rc•,,�� �v��„rs��e <br /> Phone (day): (n� d t1,'2 .3D/g <br /> Address: S�4Mt Cit : 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 i ❑ Fire Damage www.minnehahacreek.orp <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ '�� �500 <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 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 cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally 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 /> Applicant's Signature: ��v��Z�t,GL�G��l�zi�i�— Date: � a2 (? <br /> �as' Updatec 05-0�-200� <br />