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7 1 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: �/o`Ol� <br /> �,0,�. PO Box 66 <br /> O �R, O <br /> Crystal Bay, MN 55323-0066 Date received: -/Q � / <br /> �``:�� �- Received b <br /> a ��� ���-.?� �, Street Address: Y� <br /> �',�,����g" rv°� 2750 Kelley Parkway Plan review fee: <br /> 9kESH�g' Orono, MN 55356 <br /> — Total Fee: �3 .� <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 prinf) <br /> GENERAL INFORMATION: // <br /> Job Site Address: �7 �-� �• ���� `s� <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 INFORMATION: <br /> Name: �i9fLEN yyiti,T-�'YlO�� <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATIq N: <br /> ►vame: L�y /�/%/}'7dnG <br /> Phone (day): 6 S /� ?.S./- �' <br /> Address: � U.3 � L.,f�'.�E .%- City: U�'�d ZIP: �s-� S� <br /> Email and/or Fax �{i9yG�iV J/1/� �'�T�/�.9jL • GG� <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 /> i � <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: �jpG�GE �f�/T"E W/�YQo1vS ��►/ Sv y�' g���� ��� <br /> � <br /> Estimated Construction Valuation of Project(excluding land) $ � a �Jo� <br /> APPLICANT ACKNOWLEDGEMENT: Sff�"�c������,�d,"��(f�S���'t� <br /> • Agrees to provide all information required or requested by the Building Department; La l�/ y 0�, ��' <br /> ,J�/�,d.0o/� <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 /> ApplicanYs Signature: Date: ��/�Z�� <br /> � <br /> Last Updated: OS-04-2009 <br />