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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: <br /> ��,�. PO Box 66 <br /> � �\ Q Crystal Bay, MN 55323-0066 Date received: <br /> �� <br /> (,� r�4-!.;� ,, Street Address: Received by: <br /> �' � '� 'q`�y ti 2750 Kelle Parkwa <br /> � � Y Y Plan review fee: <br /> 't<9gESH04�' 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �� � � C2�� �'�t�-� � l C� ✓�'"l� C <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � <br /> lf yes, a special event permit is required with Polrce 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/APPLICANT INFORMA�T IONr• <br /> Name: �'��l t�<,��� f K�---v+��-� <br /> State License# �.�z; ������ Expiration Date: ��� � �x.c,i� <br /> Phone: ��-�.-��� Z{a�-�(�,�� (office) � (cell) <br /> Mailing Address: �{�( S c«<-�-�Q (' � �/ Cit � �t�,. �. �;,�ti ZIP: S-3 � <br /> _,� <br /> Contact Person: T�,,;�. ,� fie �.,., Applicant is: Contracto r> Homeowner (Circle One) <br /> Email and/or Fax: `��---� <br /> PROPERTY OWNER I�IFORMATION: <br /> r— �9 <br /> Name: ��.t S 3_ J c��X � � i,v �,S <br /> Phone (day): <br /> Address: {�1(�<� Lc�k� � ;��� -�Q vv c�c Y City: C �Lt� Lc�� 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 /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: .r��;,, C�� Vz , � �. ��;��' <«v« <� c__ <br /> Estimated Construction Valuation of Project(excluding land) $ 5, S� <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 infiormation is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refus.e to su I the informati�n,the a lication ma not be issued. <br /> / <br /> ApplicanYs Signature: �----~%� �! Date: %O ? l� <br /> ; <br /> LastUpdated: 05-04-2009 <br />