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/ , ;�j,�!.?�� � .�� , o� �i �,i�; �^ <br /> v! <br /> � � City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> — Mailing Address: �p�p_�g� <br /> ,/ � � PO Box 66 Permit number: <br /> ' � ��� Crystal Bay, MN 55323-0066 Date received: �/5/� <br /> � � <br /> ��0 .� O <br /> I �'�'1:�' �� Received by: <br /> � a '��t���;:� �.�; StreetAddress: <br /> �'s',�, , � Gti``' ' 2750 Kelley Parkway Plan review fee: <br /> L�kESHo4'� Orono, MN 55356 <br /> ��__'_� ��.�7� <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: -� �� �-- (�G� 11 ^ / <br /> Job Site Address: ��<�°'� ���- / 1/ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Po/ice Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be <br /> required unless app/icant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICA�T INFQRMATI . <br /> Name: � /� ��'��� � � �G��� ' <br /> State License# � �2 Expiration Date: - ;3/ - � <br /> Phone: 9�Z— 9Z — l�l/v (office) ( Z �('�3 L�/.S:S' (cell) <br /> Mailing Address: o'-/ �i u• � S✓;lc Z70 Ci : /'�P�-�' ZIP: �/t/ <br /> Contact Person: � a„F�.-, r�. Applicant is: nt act / Homeowner (Circle One) <br /> Email and/or Fax: �SL ; 9 LG ' ,� � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �� ��/v� <br /> Phone (day): �L - �l7(, - �" �o <br /> Address: �.-���� ,/�/ Cit :C.Uf�1so l� 71,�'�IP: ��9� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ 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 /> e-roof ❑ Fire Damage www.minnehahacreek.orc� <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ ` , Q(�� <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: <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 rovide on this application is classified by State law as either private or <br /> confidential. Private data is information which er ly cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information whic en II cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this inform ��� o a ally update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su e ira#Orm � n,the a lication ma not be issued. <br /> �— <br /> ApplicanYs Signature: Date: � y < `� � ��' <br /> /i`'� <br /> Last Updated: 05-04-2009 ✓ <br />