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� c� � .� � � <br /> City of Orono 7 � <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: ��/v_v��' <br /> O�,D,�.O PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: ������ <br /> I� �4� � I�� Received b : <br /> ,� �' ���; �, Street Address: Y <br /> 's',�, � ti"� �ti 2750 Kelley Parkway Plan review fee: <br /> ��ESH�g'� Orono, MN 55356 <br /> Total Fee: �Q�, �,� <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: '� ,�C� ��re5 � ln,�y1d��1 —' Q ��3vL.Q - � J 3 �J <br /> Will this be a Parade of Homes, Remodelers Showcase Home or ot r Display Home? ❑ Yes o <br /> !f yes, a specia!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 /> CONTRACTOR/APP y�T�INF RMATION: '� �^ <br /> Name: �%��`� � �� � �C' <br /> State License# Expiration Date: <br /> Phone: ���'� — �"15 (office) (cell) <br /> Mailing Address: Cit : ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner � (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFOR ATION: � r <br /> Name: ; � ��` 1 �� <br /> Phone (day): �-2.— � 2— � �° <br /> Address � Y',� `r � .L.�-r�-U% Cit : � ZIP: � S �j � <br /> Email andbr Fax w r,vv I F � P fi� � <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 /> Re-roof ❑ Fire Damage www.minnehahacreek.orp <br /> Ov II Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ � <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 uired b law. If ou refuse to s the information,the a lication ma not be issued. <br /> i <br /> ApplicanYs Signature: �L � Date: p�-(� �' <br /> Last Updated: 05-04-2009 <br />