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�67%l�12011 15: 46 6519824587 ARI PAGE 02J02 <br /> , . City of Orono <br /> r Ruilding Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: _ � <br /> O.g,D,�O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Dste reseived: 7/ / <br /> � a Street Address: Received by: <br /> �y 2750 Kelley Parkway Plan review fee: <br /> �.qkEeHo$� 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 wifl be returned, (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address; ��� ���ee� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> /fyes, s speclal event permit is requiied wi[A Pol/ce Department and City Counci!epproval 80 days prlor to the event. Shuttle bus service wil!be <br /> required unless appllcant demonstrates su�cient on-slte parking is available. Non permitted events wlll not be allowed. <br /> CONTRACTOR I APPLICANT INF RMATION: <br /> Name, �� �� u�a,-, LG� <br /> State License# _ �o � ��� g -7 Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prior to 1978 <br /> Phone: ��/.. �"2 � (office) (�.�/ _ (cell) <br /> Mailing Address: / � City; k ZIP� S <br /> Contact Person: r/ A plicant is: ont�acto / Homeowner (Circle One) <br /> Email and/or Fax: i, �7 ,� � p� <br /> PROPERTY OWN�R INFORMAT N: <br /> Name: <br /> Phone(day): � � �Q'/'7 � 7 r� <br /> Address: ,.j'ri'� '� ` ,/I Qgi�/(�?j City:_a'gan,�,� ZIP: �s,3�1 / <br /> Email and/or Fax � <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may r�quire <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed�istrict(MCWD) <br /> ❑Window(s) ❑ Repair �''btorm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑ Other: (specily) Deephaven, MN 55391 <br /> Phane: 952�71-0590 <br /> �Re-roof ❑ Fire Damage Fax: 852-471-0692 <br /> www.minn hahacreek.ora <br /> Overall Project Descr➢ption; <br /> Estimated Constructio�Valuation of Project(excluding land) $ ���o,v� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide afl i�formation requlred or requested by the Building Department; <br /> . Certifies that the information supplied is true and correct to the best of his/her knowledg�. The applicant recognizes that they <br /> are solely r�esponsible for submi(�ing a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to rejed it until it is complete; <br /> • Some or all of the infnrmation 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 eithe� the public or the subject of the data. Our <br /> purpose and intended us f this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou o su I e information the a lication ma not be issued, <br /> Applicant's Signature: � � Date: �/„2—�� <br />