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� � ��'�Iai� � <br /> � City of Orono � � h <br /> � <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> j—_—� Mailing Address: ,QOlD-4��3�l <br /> /��� PO Box 66 Permit number: <br /> �Q � O� Crystal Bay, MN 55323-0066 Date received: (p --8- /O <br /> �� �°"'`�`' ` Received b <br /> ,� `�� >,' Street Address: y- <br /> �'� � ''�� G~ 2750 Kelley Parkway Plan review fee: c?O/D -OD�38 <br /> �Rg�H�g�'� Orono,MN 55356 <br /> � ---- �a q.2x � <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 retumed. (Please print) <br /> GENERAL INFORMATION: r� , ) <br /> Job Site Address: S�� l-e1�hA�� l�°.d ^� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a specia/event permit is�equired with Police DepaRment and City Counci!approva/60 days prior to the event. Shutt/e bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI ANT INF RM��N: <br /> Name: <br /> State License# 2.0(3C�2'�- Expiration Date: c�3 ZO( � G��I�� <br /> Phone: "7(03-�4�xl-- 2��1 office Ma�n- '�r- (vl2-�](v4 -'S33O cell a�,{5 <br /> Mailin g Address: 1 �I� <{-2 ,A�J E � � C i t : l ✓n o v� Z I P: S S � <br /> Contact Person: �-�-- Applicant is: ontrac or / Homeowner �c�.ue o�� <br /> Email and/or Fax: yY1 Z[7C%�'t(�'v� � W15 y� ,C:;:�vr� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �f�cl�L-- �/}f��� <br /> Phone (day): s2— ' f3 �, q <br /> Address: � � f-��.J�/�� �� D /l� � City� {,J �y�;� ZIP� ��� 1 � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ��tS�� ��� 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 /> ❑Re-roof ❑Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ 2����� , oe� <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 staif 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 inf matio , e a lication ma not be issued. <br /> --�' <br /> ApplicanYs Signature: Date: ��' /�8 �-'�'�� <br /> Last Updated: 05-04-2009 <br />