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AUG-a8-2011 08:16 From: 6785736615 To:9522494616 Page:1�1 <br /> - . Vl <br /> . <br /> City of Orono � <br /> Buiiding Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address; Permit number; <br /> O,�Q�O PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received; <br /> Str�et Addiass: Received by: <br /> m � T � 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> ���°�G Total Fee: <br /> Main: 952-249�600 FaY: 95z-249-4616 www.ci.oronQmn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incompl�te applications will be returned. (Please pnnt) <br /> GENERAL INFORMATION: <br /> Job Site Address: <br /> Will this be a Parade of Ho es, Remodel hvwcase ome or other Display Home? ❑Yes o <br /> !!yes,a spec�al event pe�nit is requUed with Police oeparrmant and City Council approval 60 days prfor to the event. Shutt/e Dus s rvice wiil be <br /> required unless epplicant demonstrstes sufficient on•site paNpng is available. Non-permitfed events will not be allowed. <br /> CONTRACTOR/APP CANT INFO/RMATION: <br /> Name: �� Gv� C D�^S ��,L c C <br /> State License# Expiration Date: � <br /> Lead Certification Number: Expiration Date: <br /> (for wark on homes that werr constructed pifor to 1978 <br /> Phone: Cy( � �(p� � (office) ��� ��� (o���i (cell) <br /> Mailing Address: � � �/„ City: �,rr,r ��I,� ZIP: �'�3 � <br /> Contact Person: �' ( � ,.,m„� Applfcant is: Contractor / Homeowner (Clrcle One) <br /> Email and/or Fax: ��' �� S �-� [r�{ <br /> PROPERTY OWNER INFORMATIOId: <br /> Name: b� �v� �� <br /> Phone (day)' [ <br /> Address: � City_ ' � ZIP: S�S�j <br /> Email andlor Fax <br /> PROJECT INFORMATIOfd: <br /> Type of P►oject: Any earth movement m�y require <br /> MCWD review&permils: <br /> ❑Door(s) ❑Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Rep�ir ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Restoration ❑Other� (specify) Deephaven,MN 55391 <br /> ❑Siding Phone� 952�71-0590 <br /> `�Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> ww�N minnehahacreek.ora <br /> Overell Project Description: J2� — <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APP�ICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information r'equired 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 /> el'e solely r�ssponsible Eor submitting a complete application being awar'e that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> . Soma or all of the information that you ere asked to provide on this application is classified by State law as either private or <br /> Confidential. Private data is informatlon which generally cannot be given to the publ'�c but can be given to the sub��ct of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Ou� <br /> purpose and intended use of this information is to annually update our recor'ds and records of other govemmentel agencies <br /> re uired b law. If ou refuse su I the inFormation the a lication ma not be issued, <br /> ApplicanYs Signatu�e: Date: <br /> lasl Updated: 03-01-2011 <br />