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i City of Orono Building Permit Application fior Internal Work (windows, doors, siding, re-roof, etc.) ��-__- Mailing Address: Permit number: ��.,�,jV.\ PO Box 66 , O� Crystal Bay, MN 55323-0066 Date received: a 'y „ s,l) Street Address: Received by: �'��'�` 1 �',�, � "� ��ti 2750 Kelley Parkway Plan review fee: �sgE$Ho�`� Orono, MN 55356 _- Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www ci orono.mn.us 7his application form muSt be completed in full�nd all required infom�ation must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: f Job Site Address: 9y�' �0,� furr�'1 �YC� ' _�5 �� Will this be a Parade of Homes, Remodelers Showcase Home or other Displ y Home? Yes o !f yes, a specia/event permit is requi�ed with Polrce Department and City Council approva/60 days prior to the event. Shutt/e bus service will be required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events wiN not be allowed. CONTRACTOR/APPLICANT INFORMATIO� Name: �.'d� �i�,C G � � i C/ � .0 S' State License# Lp � Expiration Date: 3 �� Phone: - �s- C�� office ,� - 7 /- � "' cell Mailing Address: 6 S (b ' Ci : � ?rG�� ZIP: .5"S3 Contact Person: i L Applicant is: Contra tor / Homeowner �c�rc��one� Email and/or�ax: / U �� r� S . CO/yI PROPERTY OWNER INFORMATION: / "� Wame: �lCv� � l�7' �C"�G►'C� Phone(dayj: � - - � 3 Address: c, �' Ci : C�l'G�/1 ��!'� ZIP: � � Email and/or Fax i PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review 8�pertnits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Windovy(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 iding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 / Fax: 952-471-0682 [�'R�roof ❑ Fire Damage www.minnehahacreek.orq Overall Project Description: Estimated Construction Valuatfon of Project(excluding land) $ L�g" /(,y APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are sole�y responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies re uired b law. If ou refuse to su t the information,the a lication ma not be issued. . Applicant's Signature: i�� , 'N� Date: �'�y' �-!`��. Last Updated: 05-04-2009