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� City of Orono <br /> - Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> O Mailing Address: <br /> � ,��� PO Box 66 Permit number. � <br /> � � ��\ Crystal Bay, MN 55323-0066 Date received: <br /> �� � II <br /> a � s �, � Street Address: Received by: <br /> �� �� ���' � 2750 Kelley Parkway Plan review fee: <br /> t�kESH04�' 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: �� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isp ay 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 6us 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��� y�(,� 'I��� <br /> State License# � �j �(� Expiration Date: <br /> Phone: Z office cell <br /> Mailing Address: ( ()Z� K %� �(��(,, '� C� : ZIP: <br /> Contact Person: ti-bU -/ Applicant is: Contractor / Homeowner (CircleOne) <br /> Email and/or Fax: – Z-Z . � <br /> PROPERTY OWNER IN�ORMATION: / �� <br /> Name: �vL (., <br /> Phone (day): � `7 So <br /> Address: 1 v �f,�CL— Cit : �y"Z��vC� ZIP: � cl <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door s MCWD review&permits <br /> ( ) ❑ 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) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> ; <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 i ormation which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use is i ormation is to an Ily update our records and records of other governmental agencies <br /> re uired b law. If ou ref to su the' formati , th a lication ma not be issued. <br /> ApplicanYs Signature: Date: s �`��O <br /> Last Updated: 05-04-2009 <br />