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TomTotall 952-975-0982 p. l <br /> ..r - - . <br /> City of Orono <br /> Building Permit Appiication for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: PermR number. Cxci l�i-liG' �'j/,(� <br /> Og�,�0 CO�BaoxBay, MN 55323-0066 Date received: '�I'��b//D <br /> � St►eet Addr�ss: Received by: <br /> �� 2750 Kelley Parkway Plan r+eview fee: <br /> �ag�o$� Orono,MN 55356 <br /> Tota�Fee: � 7 �y�.�s <br /> Main: 952-249-4600 Fax: 952-249�616 www ci.orono.mn.us <br /> This application foRn must be completed in full and all required infoRnation must be submitted. /� � ,L <br /> Incomplete applicatlons will be retumed. (P/ease print) C�C -�t- <br /> GENERAL INFORMATION: � S�� �_ ���� <br /> Job Site Address: ck� E� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes fJo <br /> H yes,a special avent parmit�s required wim Po/ice Department end City Counci►approval 60 days prior to the event. Shuttle 6us seroice will be <br /> requi�ed unless applicanf demonstrdtes sut6aent on-sife parldng is available. Non-�Sermrtted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFO TION: <br /> Name: � ( j � <br /> State License# "Z C�c� � Expiration Date: �� � ?� -z�/ L <br /> Phone: O�� office 6 ' cell� <br /> Mailing Address: CP � , Ci : ZIP: <br /> Contact Person: � Applicant is: Contractor / Homeovmer �c�.u.o„o� <br /> Email and/or Fax: -�,�.�-�-����,-�� , C c�.-. _ <br /> PROPERTY OWNER FO INATION• <br /> Name: /�i � �—i�v�=�(` � <br /> Phone(daY): 9S'�- �i 3 � �! � �1 — <br /> Address: �p..� 1-�ti` ��-� CttY" CJ/�i)� ZIP� <br /> Email and/or Fax — <br /> PROJECT lNFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ❑Remodel M������� <br /> ❑Water Damage <br /> ❑Windo s Minnehaha Creek Watershed Districi(MCwD) <br /> w( ) ❑i2epair ❑Storm Damage 18202 Minnetonka Bivd <br /> ❑Siding ❑Restoration DeePhaven,MN 55391 <br /> ❑Other. (speafy) Phone: 952�71-0590 <br /> Fax: 952�74-06B2 <br /> ❑Re-roof ❑Fire Damage www.minnehahacreek.or4 <br /> Overall Project Description: �.- � �- /--� ..�� <br /> _ Estlmated Construction Valuatlon of Project(exctuding land) S ('D� f� � � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Ag�es to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is trve and oorred to the best of his/her knowledge. The applirant r�ecogn¢es that they <br /> ar�e soleiy responsibie for submitfing a complete application being aware that upon failure to do so,the staff has no altemative <br /> but to rejed it un61 it is complete; <br /> • Some or atl of the infonnation that you are asked to provide on this application is dassfied by State taw as either private or <br /> confidential. Private data is ir�formation which generdl{y cannot be given to the public but can be given to the subjed of the <br /> data. ConfideMial date is informa6on which generally cannot be given to either the public or the subjeat of the data. Our <br /> pwpose and iMended use of this informabon is #o annually update our records and records of other govemmental agencies <br /> ui�d b law_ If ou refuse to su { the infortnation,the a lication ma not be issued. <br /> -� G� <br /> ApplicanYs Signature: - Date: /��G"�v <br /> � � — <br /> i' <br /> Last Updated: 05-04-2009 <br />