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City of Orono ' Building Permit Application for Internal Work �� (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: O�,0,j�.O PO Box 66 � \� Crystal Bay, MN 55323-0066 Date received: � �'°�`"�� Received by: 1a � �;�;, s.) Street Address: \��'�, �ti``'/� 2750 Kelley Parkway Plan review fee: te;g�Ho�.� Orono,MN 55356 ' Total Fee: Main: 952-249-4600 Fax: 952-249-4616 wv✓w ci orono mn us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: %/�� i'��j��y,.-�� .�-�<f Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ❑ No If yes,a specia!event permit is required with Police Department and City Council approval 60 days pnor to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-srte parking is available. Non-permitted events wilf not be alfowed. CON7RACTOR/APPLICANT INFORMATION: Name: �yrr��z i��:t i��.�vc- ��.;,,��;"� — ,�f=�T ,� C��,5��-�.�,c� State License# �vG jio/L� Expiration Date: � 3i .at,2 Phone: 7c 3 y'�� - G�a i (office) �G..a ��e - Gso� (cell) Mailing Address: i� �i� �w y S-S Cit � �y,-....Yn� ZIP: rs yy C Contact Person: ,��yT � 1=r-«>,��-�:f-,� Applicant is: ontractor / Homeowner (CircleOne) Email and/or Fax: �7��) y�� -�c� � PROPERTY OWNER{NFORAAATION: Name: �if�°�.z-�f �=<<`s"T�.�� Phone(day}: ys.�� y�y _ iq 3 S"- Address: //5'o i�Fn��rre� �.*.-�-� City: <<-�Yz�r �� ZIP: SS�S'/ Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review 8 permits ❑ Door(s) ❑Remodel ❑Water Damage / Minnehaha Creek Watershed District(MCWD) [�'Wn ow(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd ��`'/''"'�'2! Deephaven,MId 55391 ❑Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑ Re-roof ❑ Fire Damage ww�v minnehahacreek.orq Overall Project Desc�iption: <5' �w, �.� �">�;s��f.r•rs _ ��-,��«.� s°.P��•r-�=`� _ S�„�,;� 1-�� G�'^'J•vls, Estimated Construction Valuatian of Project(excluding land) $ /v 7�L APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all informatioc�required or requested by the Buitding Department; • Certifies that the information supptied is true and correct to the best of his/her knowledge. The applicant recognizes that they are so(ely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annuatly update our records and records of other govemmental agencies re uired b law. If ou refuse to su 1 the information,the a lication ma not be issued. ApplicanYs Signature: � -Date: ��/� ��G1 Last Updated: 05-04-2009