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. `. City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: ��v— g,�,�. PO Box 66 � � 1\ Crystal Bay, MN 55323-0066 Date received: � ,� �"�4�,y ,,�i S tr e e t A d d r e s s: Received by: �'�, "� '�%� �� 2750 Kelley Parkway Plan review e: r9kE5iI0g'�� Orono, MN 55356 Total Fee: a`l�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us v �� This application form must be completed in full and all required information must be submitted. /'�� Incomplete applications will be returned. (Please print) � GENERAL INFORMATION: , \ Job Site Address: ��S 1� , r�,rIJ��4 ��Z �(�. Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No /f yes, a special event permit is repuired with Police Department and City Counci/approva/60 days prior to the event. Shutfle bus service wi/l be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: /o�Q ,��srs �,� State License# Z�3$7YSI Expiration Date: �S 3/ zoi Phone: 76J yZS- O $p3 (office) 763 'yZJ-O�a3 `iZ btiY� oZ36 (cell) Mailing Address: � I o 0 - �C, �1 Cit : �� ,,,,z ZIP: �6 Contact Person: o� Applicant is: Contracto / Homeowner (Circle One) Email and/or Fax: �' 763 yZ,r- 6 I b g _ . PROPERTY OWNER INFORMATION: �� Name: dwt 4SF Phone (day): (��Z 96 0 - zd.33 Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed 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.orq Overall Project Description: �-,�- e� 2 ,�� -r�y� �,., Estimated Construction Valuation of Project(excluding land) $ �Q /�j , �� 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 his/her knowledge. 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 all 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 information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which ot be given to either the public r the subject of the data. Our purpose and intended use of this infor � n is to annually pdate our records an s of other governmental agencies re uired b law. If ou refuse to s the information,th lication ma no sued. ApplicanYs Signature: Date: �Z� ��/f� - � Last Updated: 05-04-2009