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�e'd �d101 <br /> ' � � City of Orono <br /> Buiiding Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Meiling Address: Permlt number: �� �G'—� � / <br /> Og,�,j�O PO Box 66 / <br /> Crystal Bay, MN 55323-00BB Date re�eived: ��`f!�o <br /> � �. Street Addiess: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> ly��e��,�� Orono, MN 55356 � <br /> Total'Fee: � �� �� <br /> Main: 952-248-4600 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 Slte Addresa: �.� S1� G�"�� �T �/��/✓� SS�`5 6 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or ather Display Home? Yes No <br /> If yes,a s�aciel event permit is►squirsd with Police Department end C/ty Councll approval BO days prfor to the evenk Shutt�e bus seroice will be <br /> requl�d un/ess applicant demons6at�s sufficient on-sifs perking is aveila6le. Non-pe►mifted evenfs will qot be ellowed. <br /> CONTRACTOR/APPLICANT I FORMATI�N: <br /> Name: <br /> State License# Expiration Date: <br /> Phane: (ofFce) (cell) <br /> Mailing Address: City; ZIP: <br /> Contact Person; Applicant is: Contractor / Homeowner rci�ie o�e� <br /> Email and/or Fax� <br /> PROPERTY OWNER INFORMATION: <br /> Name: /��f"yG�ir/ ly��T���//�� <br /> Phone(day)_ /-2 /- O 6 <br /> Address: O T Ci O�O�A ZIP:�ST`�6 <br /> Email and/or Fax T/�'!f}� i'+7 <br /> PROJECT INF�RMATION: <br /> Type of Project: Any earth movement may requlre <br /> MCWD review 8 permits <br /> �Door(s) ❑ Remodel ❑Water Damage � <br /> Minnehaha Creek Watershed Dfstrict(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: 952-471-0B82 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.ors7 <br /> Overall Pro�ect Descrlption: �pG✓�CE�i�lio c�,e;RF'ol.�GE�y,�rS7�i��•R• f'�/ h�`✓i�l.'¢� <br /> Estimated Construction Vatuation of Project(excluding land� $/ Do s- � i �'��, �/. <br /> 7Ts=rl��i�i4�/i�,vv I'��.f <br /> APPLICANT ACKNOWLEDGEM�NT: '1�0 ������� <br /> . Agrees to provide all information required or requested by the Buflding Department; <br /> . Certifies that the infnrmation supplied Is true and correet to the best of hisJher knowledge_ The applicant recognlies that they <br /> are solely responsible for submitting a complete apPfication being aware that upon failure to do so, the staff hes no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the informetion that you are asked to provide on this application is Gassified by State lew as eiiher private or <br /> confidential_ Prlvate data Is lnformation which generally cannot be given to the public but can be given to the subJect of the <br /> data. Confidentlal date is Information which'generally cannot be given to either the public or the subJed of the dete, Our <br /> purpose and intended use of this information is to ennuatly update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su 1 tlie Informetion the a lication ma not be issued. <br /> � <br /> Applicant's Signature: Date: 9 �-�- �a <br /> � <br /> I....\I I...�..Lr�.�- /1G 11A 7l'1fIG <br /> ti0iT0'd aS:6Z 966ti-Zz-H3� <br />