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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 /> .,��� PO Box 66 - � <br /> i�Q,.� 0\ Crystal Bay, MN 55323-0066 Date received: <br /> �i � �i <br /> I a � � ;4.�7. s. ' Street Address: Received by: <br /> ��'�n � '�"� ti��� 2750 Kelle Parkwa <br /> t , � �� / Y Y Plan review fee: <br /> `�kESH� 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: n f , � �. �' � <br /> � l �� �CCC1E�hC � �C��� K�,� � <br /> Will this be a Parade of Homes, Rem delers Showcase Home or other isptay Home? ❑ Yes o <br /> /f yes, a specia/event permit is required with Po/ice Department and City Counci/approva/60 days pr�or to the event. Shuttle bus service wi/l be <br /> required unless applicant demonstrates sufficient on-site parking is avarlabfe. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: office (cell) <br /> Mailing Address: Cit : ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFOR ATION: <br /> Name: (�rc�,��r, :��UPrh <br /> Phone (day): <br /> Address: /q/ � r-�,�ie,,hc rS /��. / r,� City: �r<<��ti� ZIP�S,S�� / <br /> Email and/or Fax �LFDLT�2(c� f��w�ct, l.ce�ti, <br /> PROJECT INFORMATION: <br /> I Type of Project: ' Any earth movement may require R, <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 /> Sidin �;L: ( ���'"� Deephaven, MN 55391 <br /> � g� ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 ,� <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage i www.minnehahacreek.orp <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ j�l *� .,y <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> I <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they i <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 /> � `'�S <br /> Applicant's Signature: � Date: ' �� ;�,�. <br /> Last Updated: 05-04-2009 <br />