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4 <br /> ' City of Orono <br /> Building Permit Application for Ir�ternal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> �,L,�,� PO Box 66 Permit number: aQ/p—�� �� <br /> Q ,� Q , Crystal Bay, MN 55323-0066 Date received: C� <br /> le�a . j <br /> �.� � •�;t-2;, s, � StreetAddress: Receivedby: <br /> �'� '� '�" Gti � 2750 Kelley Parkway Plan review fee: <br /> L9kESHOg,�' Orono, MN 55356 <br /> Total Fee: p�(�7.(� � <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 INFORMATIS�N:_, ._� <br /> Job Site Address: !- �������'._ � � <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 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/AP LIC NT NFO MATION: <br /> Name: � � �� ��l'�s �- -� rl �"- <br /> State License# Expiration Date: / <br /> Phone: ,5 office cell <br /> Mailing Address: C�L'VL� Cit : (,y;yi �9 ZIP: "-- <br /> Contact Person: C� �'' / Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: � � �' � � � <br /> PROPERTY OWNE NFORMATI N: <br /> Name: �c� ��� � <br /> Phone (day): ��� — � ,� _ �? <br /> Address: _���f'S %�,//q.���c'� d City: �I f>YI� ZI P:� ,� � `j� <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 /> FZe-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: P�'(Y �;7 '�.��gp � ;`�,�� ��� _ «,r-.' n..� j�L� <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 /> Applicant's Signature: � V Date: � �1 � �� <br /> Last Updated: 05-04-2009 <br />