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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: v���d-pQ �O V <br /> �,0,� PO Box 66 <br /> Q+A� Q� Crystal Bay, MN 55323-0066 Date received: 2 /U <br /> ���3f� Received b <br /> � �' �:'':=� s. ; Street Address: Y� <br /> �'� � �� G� 2750 Kelley Parkway Plan review fee: <br /> L�kESi�I�4'� Orono, MN 55356 <br /> Total Fee: � � 8� 1 S <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 ret rned. (Please print) <br /> GENERAL INFORMATION: , � , > G\ ) <br /> Job Site Address: ��.� �V� ! �J�� �-/-� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f 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: ��Yl��s�L �r'1�r�,�i^�L1-, �v� C <br /> State License# �/������ Expiration Date: // <br /> Phone: �� _ �_ S' office -� f—9 y 1 � cell <br /> Mailing Address: .� �j �� .�� � Cit : s��,vc�:: ZIP: � - <br /> Contact Person: �, ( S Applicant i � Co trac / Homeowner (Circle One) <br /> Email and/or Fax: �y s`d— 2l'7�' — l 7�J1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: �.� /���� <br /> Phone (day): ��-- i� ? 3 � ) �73 <br /> Address: Cit : 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 /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding Deephaven, MN 55391 <br /> ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> verall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ J�=; ��� � <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 inf mation is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su the infor ation,the lication ma not be issued. <br /> ApplicanYs Signature: Date: ���� j� <br /> Last Updated: 05-04-2009 <br />