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City of Orono <br /> i � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: �D�Q Q�Q <br /> 4v�,� PO Box 66 <br /> Permit number: • <br /> � � � Crystal Bay, MN 55323-0066 Date received: �/ � <br /> 2;�r�, <br /> ,� ��4:i,, �, Street Address: Received by: <br /> �'.�, '° °a� �ti 2750 Kelley Parkway Plan review fee� <br /> r`�kESHo'�,� Orono, MN 55356 � <br /> Total Fee: ���, 7� <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 Display 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 bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACT LIC14NT INFORMATION: ,� <br /> Name: �5�, <br /> State License# Expiration Date: k.,�, j Lol Z. <br /> Phone: � office ,� cell <br /> Mailing Address� � Cit � NZI <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF R, MAT�Q�� /� <br /> N a m e: S`E" ��y�1 �'tQ C aN�2SS� ��� ! S C.o���4� �` �w�,� ll-� <br /> Phone (day): Z <br /> Address: �_ �� Cit : � r�� �� ZIP: � � � "�f <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�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 /> Sidin�ln5�'" ' '�]'Restoration �ther. (specify) Phone: 952-471-0590 <br /> � ( Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage �� \ www.minnehahacreek.orq <br /> Overall Project Description: � o� <br /> Estimated Construction Valuation of roject excludi g la $ d <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 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 information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uire use to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: �" Date: <br /> Last Updated: 05-04-2009 <br />