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City of Orono <br /> Building Permit Application for Internal Work <br /> • (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: o20/O � ��p2�5 <br /> O�D,�O PO Box 66 <br /> �s, <br /> Crystal Bay, MN 55323-0066 Date received: /.�.23 /� <br /> Z�3- <br /> � Received b <br /> a � ��`���'a' a � StreetAddress: _(�� � Y� <br /> �'�n ' '�� �ti�' 2750 Kelley Parkway ��� Plan review fee: <br /> tRkESHo4'� Orono, MN 55356 <br /> — Total Fee: �v�� �� <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: C� � u �a f��- f�m�.� �� �1 c, /'�� S � � � <br /> Will this be a Parade of Homes, Remo elers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a specia!event permit is�equired 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/APPLIC T INFORMATION: <br /> Name: �� �K �Z <br /> State License# �dz. $S'S� Expiration Date: � °j � <br /> Phone: 7� ' f office -► 3 ��,�2�, 3 cell <br /> Mailing Address: �l G �' 'c�- ��t,+� � Cit : o �� 'R v� ZIP: S'�� <br /> Contact Person: F- Lc ' Z pplicant is: Contrac or / Homeowner (Circle One) <br /> Email and/or Fax: ,` d �--�, n y � ,� <br /> PROPERTY OWNER INFORMATION: ] <br /> Name: ,x�s- � �o F,.v�-S�. <br /> Phone (day): �( ` �' �`�9/,3 <br /> Address: � T `�S �'c-rt r- ��'' Cit : � ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�permits <br /> �Door(s) [�Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �indow(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.orp <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ (�, U <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 /> ApplicanYs Signature: 1 i �/ � Date: �� ��� <br /> �� - v <br /> Last Updated: 05-04-2009 � <br />