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� �' City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permitnumber: o�U/O—(�g�f,�j <br /> O�,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ����D <br /> � <br /> ,� �'�` 4�i� ,, Street Address: Received by: <br /> �'.�, 2 R"�� �ti�' 2750 Kelley Parkway Plan review fee: <br /> t`�kEsxo4''� 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: L-)5� �-��� d�,� (,�.� � <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: �L��n1' � Cvr�-4�r�r 'r�c �.n� <br /> State License# _ ? � �q� -7� 5 Expiration Date: b 3/o� J�� � <br /> Phone: _c�s--Z _�,3�_ y y�,,�:� (office) (cell) <br /> Mailing Address: -, - 5� S Cit : �,�, ZIP: Ss3 v3 <br /> Contact Person: ���� yL�,�` Applicant is: ontrac� / Homeowner (CirGe One) <br /> Email and/or Fax: <br /> _S �e I[��v�\nl�5�,r, ��i I d . r c.�-. <br /> PROPERTY OWNER INFORMATION: <br /> Name: �5��,.�• � 'J- .,�n� <br /> Phone (day): �j� � _ �f7� _ i 2. � <br /> Address: 4�S �Fer�na�.Q� (��( ►J CitY: (��on c, ZIP: `�5.��i � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(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: 952-471-0682 <br /> e-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: �'� -ru��� , C o�-l�-r <br /> Estimated Construction Valuation of Project(excluding land) $ 1.��� 7-�5 �;c; <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 /> Applicant's Signature: L�,�tiG�_�--� L%������ Date: OJ�Z 3 -_/� <br /> Last Updated: 05-04-2009 <br />