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. <br /> �,, City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> Og,�,�.0 PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> a =3 �. Street Address: Received by: <br /> '�',�, � Gti`S' 2750 Kelley Parkway Plan review fee: <br /> l9kESK� Orono,MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 w�vw_ci orono mn us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will b returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: <br /> Will this be a Parade of omes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a specia!event permit is required with Police Depa�tment and City Council approval 60 days prior to the event. Shuttle bus service wi e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wilf not be allowed. <br /> CONTRACTOR/APPLtCANT INFORMATION: <br /> Name: � . �'- <br /> State License# 2.c;;. Z. Expiration Date: <br /> Phone: � , ' oTfice - cell <br /> Mailing Address: '� L- Ci � ZIP: � � � <br /> Contact Person: Applicant is: Co ractor ` Homeowner �circie o�� <br /> Email and/or Fax: � � o- : � '� - <br /> PROPERTY OWNER INFORMATION: <br /> Name: �1 Cv'L.� �,'�• cx � <br /> Phone(day): �� �` ,� <br /> Address: ',�.3�T�Z,� r,���(� Z.�� City: �,�;.�)G,C,kc ZIP: ,�J3�1/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�pertnits <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 /> Re-roof ❑ Fire Damage www minnehahacreek orq <br /> verall Project Description: , .�. � <br /> Estimated Construction Valuation of ro�ect(excluding land) S �—j,uuJ <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 I se to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signa e: Date: �y/�(J <br /> Last Updated: 05-04-2009 <br />