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� City of Orono �Buiiding Permit Appiication for Internal Work ` (windows, doors, siding, re-roof, etc.) Mailing Address: Petm(t number: �' v� O,�`Q�O PO Bax 66 �O f Crystal Bay, MN 55323-0066 Date received: Received by: 1 Street Address; �/� � 4 2750 Kelley Parkway Plan review fee: `�l w° Orono, MN 55356 � � � , �� �'k�'sx°¢ Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in ful! and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATI N: � �� g I Job Site Address: �' ' � Will this be a Parade of Homes, Remodelers Showcase Home or oth r Display ome? Yes o !i yes, a special event permit is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service !be required unless applicant demonsfrates suiFicient on-site parking is availabfe. Non-permitted events will not be allowed. CONTRACTOR 1 APPLIC�T IN�R�6ATIGON: Name: '� � Expiration Date: State License# cell Phone: (� — ofFice Mailing Address: � Ci : ` ZIP: Contact Person: ' Applicant is: f� " 1 Ho eowner (Circ�e One) Email and/or Fax: — PROPERTY OWNER INFORMATION:^ Name: � / Phone(day): - � . � , Cit : ZIP: , Address: Email and/or Fax PRO.lECT INFORMATION: Any earth movement may require Type of Project: MCWD review S.permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) Storm Dama e 18202 Minnetonka Blvd ❑Window(s) ❑ Repair � 9 Deephaven,MN 55391 ❑ Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 Re-roof ❑ Fire Damage ��^�uw minnehahacreek.orq verall Project Description: � = • � — D Estimated Construction Valuation of Project(excluding land) $ � aU � 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 al{ 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 generally cannot be given to either the public or the subject of the data. Our purpose and intended use of th's information is to annually update our records and records of other governmental agencies re uired b law. If ou refuse su I the information, the a lication ma not be issued. � � Date: � Applicant's Signature: Last Updated: 05-04-2009 Z 'd SLOfrS9SIS9T oo� �Iempe� d9S �S0 OT �0 qa.�