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� <br /> ,>° ;F�� .� <br /> <�� ��< <br /> ' : �F: � , <br /> � City of Orono �' <br /> �� .��� �a <br /> 4�kk{� � �: ���� <br /> Building Permit Application for Internal Work � <br /> �� <br /> (windows, doors, siding, re-roof, etc.) � <br /> Mailing Address: Permit number: ;� <br /> g,�—� PO Box 66 <br /> � �� � \ <br /> Crystal Bay, MN 55323-0066 Date received: �� <br /> � �� � �� Received by: � <br /> a, �,�4,-�,� s, ! StreetAddress: � <br /> �' �'�w".a- Gti 2750 Kelley Parkway Plan review fee: <br /> �L`�kE,sHo�'M� Orono, MN 55356 �� <br /> - Total Fee. <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. (P/ease print) �� <br /> GENERAL INFORMATION: ',� <br /> Job Site Address: %£���' ,�`c����-�- ��—��c � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No � <br /> lfyes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be � <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. 's <br /> ;,��; <br /> CONTRACTOR/APPLICANT INFORMATION: �, <br /> Name: ��« ��,n�/ �,-.,�� �� � /�, ���,- � <br /> �. � . <br /> State License# Za 2.GP Zz Expiration Date: -� 3l i/ � <br /> Phone: /Z—Z2��-�5-`l�� (office) 6/Z �z 2-�=5`-`��� (cell) <br /> Mailin Address: 7Y�� ac��.�f/s� � <br /> g � N Cit My /c_ G��--� ZIP: �-S-.�i� � <br /> Contact Person: ���;r ��„�l�-f Applicant is� Contrac r Homeowner (Circle One) _� <br /> Email and/or Fax: �'�co�r� -�-s G� ��, cor,-� `� <br /> � <br /> PROPERTY OWNER INFORMATION: =� <br /> Name: �s� � ivf����,�- � <br /> Phone (day): '`� <br /> Address: ��'�v G.� fr-� ��."._, �T<< City:Cl��o 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 /> � <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: �� <br />�:" Estimated Construction Valuation of Project (excluding land) $ .S^�.S�o e� <br />�x. <br />��' APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; ;� <br /> ,�; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �` <br /> �s <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 />�:�r <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 /> F'� 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 /> �� Applicant's Signature: Date: �1�� 1� <br /> �f_ <br /> � LastUpdated: 05-04-2009 <br /> ��. a �� , �� � � <br /> J � ['^�r�?'�' $ C <br />.,.r, _ . .__ .... �, �_ v. .._. .. ..x..,a ..,.a:..�..'.ut.#:�a4'. _.�...., i4"�A ..w'.�Se._.�n.z,txL.S.�..�..a,'� <br />