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. . <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: ��l — bQ7 <br /> �,�,� PO Box 66 p <br /> Permit number: <br /> ' Q,;�\" Q Crystal Bay, MN 55323-0066 Date received: (� 2��0 <br /> � ��'���^,;. a, ; Street Address: Received by: �" <br /> �'� ' '" "''� ��/ 2750 Kelley Parkway Plan review fee: <br /> �` Orono, MN 55356 <br /> t`'kESH04� � D�,�/ <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: `�� E�;Y-� ��. ���� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the 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: �S(�- �'�3►�S('�lrr:�`►.L�� . <br /> State License# �,3�,�7`� Expiration Date: ��-IZ-�Z <br /> Phone: b � � �t - ,�z� office � cell) <br /> Mailing Address: Si'�S I N0.��tk1�, - l03 Cit � `� �trJ ZIP:S �y� <br /> Contact Person: �-E Applicant is: ontrac Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: `�� •��,d-�Q1.CL (7� <br /> Phone (day): �SZ- S i 3- �$7� <br /> Address: ��c�r=o� �VL',5- City: �(�►-�C� ZIP: SS �',� <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 /> �iding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ ` � �� , <br /> � <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 /> � <br /> Applicant's Signature: Date: ���' � � <br /> Last Updated: 05-04-2009 <br />