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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: <br /> �v�,�\ PO Box 66 <br /> Q ;; 0 `\ Crystal Bay, MN 55323-0066 Date received: <br /> � �� � i <br /> ��,',�e.��;. s, � Street Address: Received by: <br /> �' ��"� �,� 2750 Kelley Parkway Plan review fee: <br /> � <br /> r9kEs�04"� 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: ��,;��'��� � � ,� ��z� <br /> Will this be a Parade of Homes, Remod lers howcase 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 fhe 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/APPLICANT INFORMATION: . <br /> Name: "'� � . � ; <br /> State License# � �_.3_3��,f'y Expiration Date: �, <br /> Phone: < - � office cell <br /> Mailing Address: .�" ' L(� Cit : � - <br /> � ' ��� � ZIP: . <br /> Contact Person: .��"„,vt�� Applicant is: r '/ Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: ����c � <br /> Phone (day): 9�-� _ <br /> Address: d ; Cit : �rr��4�� 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) �epair torm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> ,�� Fax: 952-471-0682 <br /> I�Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: _ �� • �- <br /> Estimated Construction Valuation of Projec (ex ding land) $ '7 . <br /> 1' , ' �' �.; <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 th, inf rmatio the a lication ma not be issued. <br /> ' ;� <br /> ApplicanYs Signature: �' � Date: - , � , <br /> Last Updated: 05-04-2009 <br />