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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 /> Q �\ O Crystal Bay, MN 55323-0066 Date received: l b ����d <br /> �;��. I <br /> a '" 4��, �, Street Address: Received by: <br /> �'.�, 9� Gti 2750 Kelley Parkway Plan review fee: <br /> �9kESH0�`'� Orono, MN 55356 <br /> Total Fee: (�..5��5� <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: �� F�p_,���,£ ,f'�D, ,cl: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [L�-f�o <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 will6e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: i 6'/���1r�3 i� ,�c F�.S . .uC� <br /> State License# ,;2ola����f Expiration Date: 3 3l !/ <br /> Phone: �,�'z- �7f- (,-?7? (office) (o�2-7S�,- �'/!o (cell) <br /> Mailing Address: Zo 3 � w /.��.G'.fI Cit : ZIP: <br /> Contact Person: � Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: �`,�� � -�,�� �� u,�- �� <br /> PROPERTY OWNER INFORMATION: <br /> Name: JT,¢�Zi,�,�,• �,�JaC�.s�J <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <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 /> [t]�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 /> U✓ Ke-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ �fr'f� ('p.cP,2t <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <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: � . D"�--� Date: Q Zv D <br /> Last Updated: 05-04-2009 <br />