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� � ��'�� �'�; �` � �" � . , , � � � , � City of Orono y Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) %_—==�� Mailing Address: � �'�'��T�� PO Box 66 Permit number: � �—�� Q ,� Q\� Crystal Bay, MN 55323-0066 Date received: ��r�t Received by: �a �� `.r � . F � Street Add�ess: �'�,n ��y,;��>, ��/ 2750 Kelley Parkway Plan review fee: L ��"��" � � Orono, MN 55356 `�kEsxo�''i -- ` _ = Total Fee: ; ''< Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � l ;' ' This application form must be completed in full and all required information must be submitted. Incom lete applications will be returned. (P/ease print) GENERAL INFORMATIOt�.- �� I Job Site Address: S ��, ' �; �;j� (; Will this be a Parade of Homes, Remod ers Showcase ome or other Display Home? ❑Yes No If yes, a specia!event permit is required with Police Department and City Council approval 60 days pnor to the event. Shuttle bus serv�will be �equired un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/A LICA I FORMATION: Name: �If�'�� State License# v ( G Expiration Date: 3 �7 � J�2 Lead Certification Number: - -� Expiration Date: 7 ��'"j- (for work on home that were constr cted prior to 1978 Phone: � -� —�2(j{) (office) (cell) Mailing Address `n�'j .�1L� � City: �,{,; ,S ZIP: Contact Person: �V �/,�{S' ( ^ q(�.i/1Applicant is� ontract / Homeowner (CircleOne) Email and/or Fax: PROPERTY OWN INFORM, ION: Name: YC� ��, Phone (day): �' - ' � Address: �j � ��, City� (/l (,) ZIP: Gj✓�r Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require �WindDoor(s) ❑ Remodel ❑Water Damage MCWD review&permits: ow s Minnehaha Creek Watershed District(MCWD) ( ) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑ Restoration ❑Other: (specify) Deephaven, MN 55391 ❑ Re-roof /� Phone: 952-471-0590 ❑ Fire Damage � �G Fax: 952-471-0682 www.minnehahacreek.orq Overall Project Description: �a(',� . �,� � � � , ir✓ � � Estimated Construction Valuatio of Pro�ect(excl ding land) $ � , APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building DepaRment; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative 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 refu e to su I the fnformation, the application may not be issued_ , ,`\`__ --�— � � ApplicanYs Signature: � �j 1 l ., v�� -�' Date: � r�l � Last Updated: 03-01-2011 � (y�� 7�- �j � 1 ��,� lh��! ��,�n�� -j� (��'p�i,� I M