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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: ���b - ��d <br /> O��,�.0 PO Box 66 � � <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ,� �� � Received b <br /> '' .,k��, �, Streef Address: y' <br /> 's',�, r� y�� �ti�' 2750 Kelley Parkway Plan review fee: <br /> t`�kEsxo4''� Orono, MN 55356 <br /> Total Fee: � /„�5 �3 <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: <br /> Job Site Address: �;a�' ���,.� P�SS <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 Pofice Department and City Council approval 60 days prror to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is availa6le. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: A�� Sc'�t S�r �%w:�c�%.�.� rl-���. GCc <br /> State License# �-,�c���i Expiration Date: 3�,� <br /> Phone: office cell <br /> Mailing Address �.� �{ _ti �� Cit : • q.�, � ZIP: v� <br /> Contact Person: �(,t�(r� �G,,acQ.�r Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �'1�:�k S'�r�l�( <br /> Phone (day): <br /> Address C'� ,_ , 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: e�✓ S g � '�, � (r� <br /> Estimated Construction Valuation of Project xcluding land) $ 6 <br /> l <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 inform tion hich gener Ily cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of t � inf mation is annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse u the ' or tion,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: <br /> �1�� -iv <br /> Last Updated: 05-04-2009 <br />