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May 26 10 06: 39a John Volkmar 952-471-3155 p. l <br /> � • ' <br /> � � City of Orono <br /> Buitding Permit Appiication for Internal Work <br /> (windows, doors, siding, �e-roof, etc.) <br /> Mailing Addrsss: Permit number. �/�- $' <br /> .�O PO Box B6 <br /> O O Crystal Bay,MN 55323-0066 Date received: �o� �/� <br /> a �, Street Address: Received by. <br /> '� �.,ti 2750 Kelley ParlcwaY' Plan review fee� <br /> � Orono, MN 55356 � <br /> Total Fee: �p�Q � <br /> in: 952-249-460U Fax: 952-249-4616 w�vw.ci.orono.mn.us <br /> his application fortn must be completed in f�ll and all required information must be submitted. <br /> Incomplete applicatiohs�will be returned. (P/ease print) <br /> GENERAL I FORMATION: � <br /> Job Site Ad ress: <br /> WII this be a Parade of Homes, Remodelers Showcase Home or'other Display Home? Yes �No <br /> If yes,e speci !evenf permrt is required wffh Police Department and City Council approva!60 days prior to the event. Shuffle bus servlce TI be <br /> qulred un/ess applicant demonsfrafes su�cient on-slte parking is availab/e. Non permitted events wil!not be allowed <br /> CONTRACTO /APPLICANT FORMATlON: � <br /> Name: <br /> State License ' Expiration Date: <br /> Phone: (office) (cefl) <br /> Mailing Addre s: City: ZIP: <br /> Contact Perso : Applicant is: Contractor / Homeowner �cir�e one� <br />� Email and/or•F : <br /> PROPERTY INFORMATION: ' <br /> Name: �,�d1r�,Y� U8 ��1'!Ct� <br /> Phone(day): <br /> Addres5: � (n�{a r,��.l l_y ��h+��cca1�'i�� ZIP: S 5,33 j <br /> Email and/or F G�,S�— 471�' �/ S S <br /> PROJECT 1 FORMATION: <br /> Type of Proje Any earth movement may require <br /> MCWD review S permits <br /> ❑ Door(s) ❑Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Storm Damage � 18202 Minnetonka Btvd <br /> Deephaven,MN 55391 <br /> �Siding ❑Restoration ❑Other. (specify) Phone: 852-47'1-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑Fire Damage www.minnehahacreek.orq <br /> Overall Pro' Description: ' <br /> Estimated Co struction Valuation of Pro'ect excludin land b D• <br /> APPLICANT CKNOWLEDGEMENT: � <br /> • Agrees o provide al!informa6on required or requested by the Buildit�g Department; <br /> • Certifie that the information supplied is true and corred to the best of hisfier knowledge. The appficant recognizes that they <br /> are sol ly responsible for submitting a complete application being aware that upon failure to do so,the staif has no alternative <br /> but to r 'ect it until it is complete; <br /> • Some all of the infortnation that you are asked to pravide vn this appiication is classified by State law as either private or <br /> corifide tlal. Private data is information which generally cannot be gi,ven to the public but can be given to the subject of the <br /> data. onfidenGal data is iniormation which generaly cannot be given to eAfier the public or the subject of the data. Our <br /> purpos and intended use of this informatien is to annually update ou� records and records of other governmerrtal agencies <br /> uire b law, lf ou refuse to su I the i�ormadon the a liqtion ma not be issued. <br /> ture: V Date: � �a�"�^ �0 <br /> AppbcanYs Sig a ��tX/� <br /> Last Updated: 05- 2009 ' <br />