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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 /> 4v�,� PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> j! 0����;��. O <br /> a � e�;�. �, Street Address: Received by: <br /> �'�,n ' '9� �� 2750 Kelley Parkway Plan review fee: <br /> �`�kEsxo4`� 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. (P/ease print) <br /> GENERAL INFORMATION: � <br /> Job Site Address: C��� ��C����� �'�� <br /> Will this be a Parade of Homes, Remodelers Showcase 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 the event. Shuttle bus service will be <br /> required unless appficant demonstrates sufficient on-site parking is available. Non-permitted events will not be alfowed. <br /> CONTRACTOR/APPLICA�I T INFORMATION: ,� <br /> Name: ' <br /> State License# Expiration Date: <br /> Phone: � office cell <br /> Mailing Address: U C' U�'t- (./f� Cit : ZIP: `i � <br /> Contact Person: � t� Applicant is: ontractor Homeowner (Circle One) <br /> Email and/or Fax: - <br /> PROPERTY OWNER INFORMATION: � <br /> Name: yZ�' /�/� ' <br /> Phone (day): /� f ( <br /> Address: � Cit : ��',�J ZIP: �,3,�'0 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�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 /> ❑ Siding ❑ 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) $ � �j <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 s e information, the a lication ma not be issued. <br /> Applicant's Signature: Date: � �� � <br /> Last Updated: 05-04-2009 <br />