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.. . City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: /��0,�.�� PO Box 66 Permit number: //� Q\� Crystal Bay, MN 55323-0066 Date received: �� ,��r�,�_;,� �.�� Street Address: Received by: .� . '� ti 2750 Kelley Parkway Plan review fee: �� Orono, MN 55356 �'?fEssosL '-_--' Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be retumed. (Please print) GENERAL INFORMATION: Job Site Address: �S8 7 � ��. Will this be a Parade of Homes, Remodelers Showcase ome or other Display Home? Yes No If yes,a specia!event permit is required w�th Pofice Departmenf and City Counci!approval 60 days prio�to the evenk Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT IN ORMATION: Name: _ �G� �:ll �C- State License# a o�,yp,p j� Expiration Date: ��3//„�olZ Phone: �- �, - o�ce ' celt Mailing Address: Z 6 5' .S Cit : �ru ZIP: ,5;j3 Contact Person: �'� �� Appl�nt is: ontractor / Homeowner (Circle One) Email and/or Fax: �, ' � � � ,�,� ,� PROPERTY OWNER INFORM TION: Name: � �c� �' Phone(day): �/� - f; 7 - ,36 Address: _�.��'7 KP/l� ��'- City. �/'a/�rG ZIP: S.S3r'�'� 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) ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑Siding ❑Restoration ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 Re-roof ❑ Fire Damage www.minnehahacreek.ora Overall Project Description: P oC� Estimated Construction Valuation of Project(excluding land) $ ,�d p ,�.p APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . Ceriifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it unti�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 infortnation 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 annually update our records and records of other governmental agencies re uired b law. If ou refuse to su I t ation,the a io a not be issued. ApplicanYs Signature: GzG� Date: _��y`—� .��J/� Last Updated: 05-04-2009