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. City of Orono <br /> � Building Permit Application <br /> �� Mailing Address: Permit number: Qd�—dd�7� <br /> �g,0,j�.� PO Box 66 <br /> � �A Crystal Bay, MN 55323-0066 Date received: �l D � <br /> i; � h 1 <br /> �i� � I� Received b <br /> ��',�s;`_ a, � Street Address: y� <br /> ��'.�,�'���,� oti��� 2750 Kelley Parkway Plan review fee: ���LC c cX.� ' <br /> �kESKo4�� Orono, MN 55356 �� <br /> ---�� Total Fee: 4�' � --, (L-,(� <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: ! r-;` �F:- �Jx 5 ���;s>_� - <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 Crty 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/APPLICANT INFORI�IIIATION: -, <br /> Name: ���L�=�v ��,<-L��t � � -,�, ;.� �L+�c.+���s=-'vt , .L-�_, �. <br /> State License# �� �<<; �j � Expiration Date: 3 - 3l - %c:_� <br /> Phone: � .� �,. ��' ; _ 3.�,`i (office) , _<1���� �_ ��� �_ (cell) <br /> � ; <br /> Mailing Address: � ',�; •� � Cit �Z , � Zlp: t,� �,`� <br /> Contact Person: ��_ i �r�,U � �_-- Applicant is: ` ontra o ' / Homeowner �CircleOne) <br /> Email and/or Fax: �+�1,,� ,�� '�c_a ������„��t�,���� ����.L--� <br /> PROPERTY OWNER INFORMATION: fJ <br /> Name: �)i.:�i E.1-1(:� ���r(��/� �� l L[.•�.�-'-1 <br /> Phone (daY): � l 7 �-7£: b�=. Z-Z { <br /> Address: U7__ l�': �ZN;n,���1 � �'�-�_ >�:. CitY� 11! IL�-.>> ZIP: L� `f�'<I <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 /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.or <br /> Overall Project Description: �!,' �,�;;,� ,,, � � �- �_-y ,�- �� , , ��.� <br /> Estimated Construction Valuation of Project (excludin 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 /> required by law. If you refuse to supply the information, the application may not be issued. <br /> F ' ', 1 �-�� �•> <br /> ApplicanYs Signature: ` " �� \ Date: � - G-1 �� t <br />