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�. City of Orono � Buifding Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) MailingAddress: Perrnit nurnber: CO �1 � -CC%� �lc O,¢(��O PO Box 66 • Crystal Bay,MN 55323-0066 Date received: �-�% � �� 1 � �, Street Address: Received by: Y- �� 2750 Kelley Parkway Plan review fee: ��ESH04'� Orono, MN 55356 c. Total Fee: 4 g� , :�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATlO • � 1 � � �� / /, � �� /� 5 � 3 y � Job Site Address: �v� �� w b`f7 �II this be a Parade of Homes, Remodelers Showcase Home or o er Display Home? Yes No If yes,a specia!event permif!s required with Police DepaRment and City Counci!approva160 days prior to the event. Shuttle bus service � e required unless appficanf demonsfrates sufficienf on-s'rte parking is available. Non-permitted events wrA not be allowed. CONTRACTOR/APPLIC NT 1NFORMATION: Name: �� State License# Expiration Date: office _ cell Phone: � ZIP: Mailing Address: Cit � Contact Person: . ' Applicant is: �ontractor Nomeowner �cir��e one� Email and/or Fax: - � PROPERTY OWNER INFORMATION: Name: Z Phone (day): - � Cit : .i� ZIP: �� Address: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD revlew 8�permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watetshed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55391 ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 e-roof ❑ Fire Damage www minnehahacreek.ora Overall Project Description: � "' Estimated Construction Valuation af Project(excluding land) $ :i• APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of hismer knowfedge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or atl of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is informafion which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies re uired b law. If ou refuse to I the information,fhe a lication ma not Be issued. Q � � Applicant's Signature: Date: Last Updated: 05-04-2009 Z 'd SLO�S9STS9T �UI �liempe, e9�b �0T iT SI u�C