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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: v4/�G—a0 0� <br /> �v�,�. PO Box 66 g <br /> �,,. � Crystal Bay, MN 55323-0066 Date received: U ��� -���� <br /> � ���"�'' Received by: <br /> I,� � ���e��� �. � Street Address: <br /> �'�n �� °~� 2750 Kelley Parkway Plan review fee: <br /> t9kESHOg'� Orono, MN 55356 <br /> Total Fee: � ��D, �� <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: ,�� �'`� ��'�1�,:�c%c �' ;;�� �;��; �-� ,; � ._ ,� <br /> ZC CL- I c; 1 G � ��'t ��-��� <br /> Will this be a Parade of Homes, Remodelers Sh wcase Home or oth r 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/APnPLICANT IN�OFjMA,TION: <br /> Name: __�/c�/L � lS"t�'C� n'� <br /> State License# _��� Expiration Date: �.�/01 <br /> Phone: - Ca J '~o"i �f#+�e -/ -� - OC� ` _ � cell <br /> Mailing Address: � � (,�. Cit : �;- ZIP: '� �����, <br /> Contact Person: � �- �`= Applicant is: Contractor / omeowner� (Circle One) <br /> Email andlor Fax: , �-`. - , �� ' ���—� <br /> f .'Yt <br /> PROPERTY OWNER INFORMATION: :� <br /> Name: 1 � �� ��• <br /> Phone (day): '"� _ - ' � ) <br /> Address: � v� ac� `. Cit : f t �`., ZIP: �� :3� � <br /> Email and/orFax ��ir �c.i�n l�; 1���� rY1C' ��-S� l'�>m <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:,��-«- / �- � - ' r-� - � ,I� ? j., ,��-v���c�;' <br /> a' c ,r , � �� � cr� � < < � ���- � ����; : <br /> Estimated Construction Valuation of Project(excl ing land) � �3 �-r� k � •` � tcdi� pi� ���„fj�� <br /> �'!1�` r9�_. � � c'��¢"cc <br /> APPLICANT ACKNOWLEDGEMENT: C�:�,n�rs,� f-aU�f� <br /> • Agrees to provide all information required or requested by the Building Department; r�',rt C�r�•c':� ' ;� t�c�, <br /> `d��v�Yl;Yj✓u1 C 4 �.�,r <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 /> ApplicanYs Signature: �� � - ' � . Date: �, <br /> Last Updated: 05-04-2009 � <br />