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� • City of Orono . Building Permit Appiication for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: �26//—�� O�v�,�0 PO Box 66 � / Crystal Bay, MN 55323-0066 Date received: � , , a � �, Street Address: Received by: �'�n "� �ti�' 2750 Kelley Parkway Plan review fee: t�ESH04'� Orono, MN 55356 Total Fee: � ��J Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us i This appfication form must be completed in full and all required information must be submitted. Incomplete appfications will be returned. (Please print) GENERAL INFORMATION: / Job Site Address: `1D ��-/��S v�5 (�v� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes {�f"o !f 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: (�,�,, ` � State License# j"�C�b Expiration Date: �3 �2 Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: . -,l �`�b� �� office) 7��._ Z7� ,_v�(h � C�?�� /� (cell) Mailing Address: - S l�� City:�c� q ZIP: � ,�, Z Contact Person: ' Applicant is: o t�actor omeowner (Circle One) Email and/or Fax: - PROPERTY OWNER INFORMATION: Name: '� - � �, v Phone (day): - Z— Address: � � � � �- �, �- City: `�,��; ZIP: `� �3� Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 Phone: 952-471-�590 �Re-roof ❑ Fire Damage Fax: 952-471-0682 www.minnehahacreek.orq Overall Project Description: � "'�,-� � �. Estimated Construction Valuation o Project(excluding fand) $ � ' � � 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 solefy 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 compfete; • Some or all of the informafion that you are asked to provide on this appiication is classified by State law as either private or confidential. Private data is information which generalfy cannot be given to the pub(ic but can be given to the subject of the data. Confidenfial data is information which gener cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is annu Ily update our records and records of other governmental agencies re uired b law. If ou ref e o su I the � form ti n,the lication ma not be issued. AppficanYs Signature: Date: � � � Last Updated: 03-01-2011