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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: � <br /> �,0,�. PO Box 66 Permit number: d/� �� <br /> � ��.. � <br /> Crystal Bay, MN 55323-0066 Date received: 6 � /� <br /> �'�r'���` Received by: <br /> ,� "�;� _ �, Street Addr�ss: <br /> '�,�, �� �� �"� ���' 2750 Kelley Parkway Plan review . <br /> l9xE$HO¢�' Orono, MN 55356 � � � <br /> Total Fee.�T � 5�. 7 <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: ��V����. <br /> Job Site Address: 2.'ZO� L<.G�`�/ �• �V� — <br /> Will this be a Parade of Homes, Remodelers S owcase Home or other Display Home? ❑ Yes [� No <br /> If yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wib be <br /> required un/ess applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: /'V��•�1.�,�� �1 ol�d•� <br /> State License# Zp��(�,$9p Expiration Date: 3�31- 1 I <br /> Phone: ., Z,�{ - office cell <br /> Mailing Address: �,.r Ci : � I.CL ZIP: SS <br /> Contact Person: 1 kL IV o r 4-�-.. Applicant is: ontract / Homeowner (Circle One) <br /> Email and/or Fax: n,o r-6� S�4 L Q. c-�C4_.ri�-I-.✓te."f' <br /> PROPERTY OWNER �v FORMATION: <br /> ►vame: /:�L�t,�r 5o�ns�on <br /> Phone(day): �j'S'2+2Z 1 -7 7 y 5( <br /> Address: Z'7p0 !%c I l y �4�,.c_ City: Q(2c�1Vp ZIP:,,�'S 3 3 � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�p�rmits <br /> oor s �Remodel ❑Water Damage . �'d' <br /> Minnehaha Creek UVatershed District(MCWD) <br /> �v�) ❑ 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 ww_w_minnehahacreek:org <br /> Overall Project Description: �,�.}e,.�� � e-e,+�od� w/ Scn�.._ 1.����locv/C�co� rG(G,T, ce�,t�'�" <br /> s E�timated Construction Valuation of Project(excluding land) $ ty���pa � <br />. �.., <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 /> confid�ltial. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> � <br /> data. Confidential data is information which generatly 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 /> � <br />