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, �-�- ���� � �,,�� w'� �� �� ;�������- ��y ��ec K, ;� ��� ,��, I ��- <br /> �.� � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Marling Address: Permit humber. <br /> O.¢,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ,� z;, �, Street Address: Received by: <br /> '�,E, � . Gti 2750 Kelley Parkway Plan review fee: <br /> L9xEgH0�`'� Orono, MN 55356 <br /> Total Fee: <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 INFORMATIO�: <br /> Job Site Address: � 1� � f�✓1 C � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service !1 be <br /> required unless applicant demonstrates su�cient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: L ��'?�� 1 '� �C�'� ��'�";VC.�i� ��C,. � <br /> State License# ��j�� , � Expiration Date: _3 ;3 J 13 <br /> Phone: � � -�-f,��f � �1 � office cell <br /> Mailing Address: (�,� 1 -� �� ` � Ci : ZIP: (; <br /> Contact Person: jcv Applicant is: Contractor / Homeowner (CircleOne) <br /> Email and/o Fax1 �,51 - 351 - �C3 � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �C'►'11_�S- ►'1 <br /> Phone (day): C�;� �t��a - ��3 <br /> Address: City: ZIP: <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 /> ` e-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: ��`�� �- � �� � c. �G'ti <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 su I the information,the a lication ma not be issued. <br /> � <br /> ApplicanYsSignature: �� - � — Date: � I ��I �� <br /> Last Updated: 05-04-2009 <br />