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City of Orono <br /> , � <br /> � ' Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �,0,� PO Box 66 <br /> %0 �:\ Q Crystal Bay, MN 55323-0066 Date received: <br /> ��� �'� ,i <br /> 'r�z���,� �.�! Street Address: Received by: <br /> �' ��� �ti 2750 Kelley Parkway Plan review fee: <br /> � <br /> t�.rfESK 4� 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 INFORMATION: `�� � �E%n� � <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f yes, a special event permit is required with Po/ice 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 I AN IN�R�M�A�T�N: � /��� �` � <br /> Name: �� � �'{ ��'C l � l') �.c t�-A��� <br /> . <br /> State License# Expiration Date: <br /> Phone: _ ffice cell <br /> Mailing Address: - �t Cit : ZIP: <br /> Contact Person: Applicant is: Contract r / Homeowner (Circle One) <br /> Email and/or Fax: �i" � (o' <br /> PROPERTY OWNER INF RMATION: <br /> Name: � <br /> Phone (day): <br /> Address: Q�� City� (ty�8'f-�'� ZIP� 3 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel MCWD review 8� permits <br /> ❑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 /> Re-roof Fax: 952-471-0682 <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> verall Project Description: .(� � � + � �j�G <br /> Estimated Construction Valuation of Project(excluding lan $ 4. p <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 /> i purpose and intended use f this informati is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refus to su I the in o a ion, the a lication ma not be issued. <br /> ApplicanYs Signature: 1 Date: <br /> � g 2�� <br /> Last Updated: 05-04-2009 <br />