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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: b/D"d/b 9 <br /> ��,�. PO Box 66 <br /> � �,..��,� � <br /> Crystal Bay, MN 55323-0066 Date received: // � D <br /> �;�� ; -- Received b <br /> ,� � T �,�.z �, Street Address: y� <br /> �'�, '� ��%>� �ti 2750 Kelley Parkway Plan review fee: <br /> t�'kESH g'� Orono, MN 55356 <br /> - Total Fee: .�/�9 � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us J' ' <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: ,',;'�> J���� ��/c.� iZ 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 applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR,�,ATION: <br /> Name: � �'-f�ll .���, ���1�h� ,-t �x�-�,� ��c <br /> State License# �' 6���-�;� Expiration Date: 3��� <br /> Phone: �i� q�, �6i� (office) (cell) <br /> Mailing Address: �-3 � �,.�q ss .ti-� Cit : �,��, z ZIP: ,,�ys�-� ��3 <br /> Contact Person: �,,� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER IN�ORMATION: <br /> Name: �d,�,f z <br /> Phone (day): �ia - g�s- ��30 <br /> Address: ��� ' City: ZIP: <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 /> ��-roof ❑ Fire Damage www.minnehahacreek.or4 <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ ��c�zj� <br /> APPLICANT ACKNOWLEDGEMENT: C��'12 5���� <br /> • Agrees to provide all information required or requested by the Building Department; s �-�,y� /l l� <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 inform tion is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I e inform tio , he a lication ma not be issued. <br /> ApplicanYs Signature: Date: �//��CJ <br /> . �� <br /> Last Updated: 05-04-2009 <br />