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• . City of �rono <br /> .. <br /> ' Building Permit Application for Internal Work <br /> (windows''doors, siding, re-roof, etc.j <br /> ,._._�_ Mailing Address� Perrnit raumber. �� � <br /> /O .(�\\ PO Box 88 <br /> O 'O\; Crystal Bay, MN 55323-4066 Date received: �� � � <br /> � 1 Received by: <br /> � � � Streef Address: <br /> � 2750 Kelley Parkway Plan reviewfee: <br /> �� ag�° Orono, MN 55356 �( � <br /> ��H 7otal Fee: ,I,D���` <br /> Main: 952-249-0600 Fax: �52-249-4616 www.ci.orono.r�n.us `f� <br /> This apptication form must be completed in tull and all required iniormativn must be submitted. <br /> Incamptete applicationa will be returned_ (P/ease prirrt) <br /> GENERAL INFORMATION: <br /> Job Site Acfdress: ��(P � �Ci �� �'�� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> 1f yes,a specia!event pemxt 7s requir�d with Police Depertment and City Council approval BQ days prinr to the evenk Shuttle bus servioe wiU 6e <br /> required unlass applicant demonsbates suff'icienF on-site parkrng is available. Non-permitted events wiU rrot be allotirred. <br /> CONTRACTOR f APPLICANT IN ORMATION: <br /> Narne: ' b��� '�'t'� <br /> State License# � � ', Exp' tion Date: 3�i— !/ <br /> Phone: .. .,I office cell <br /> MailingAddress: �� � � �� �P� � <br /> Contact Person: + � Applicant is: Contractor ! Homeowner 1c��e��1 <br /> Email and/or Fax: '7 — <br /> PROPERTY OWNER I�IF�RMATION: `- <br /> Name: �4.�,r1 �1! 1� � S I�e <br /> Phone (day): 1 - `-�31� <br /> Address: � ►�'' � � �� �, �.-�j'.,�t�ft� f(, �<<y: ��-,��� Z�P: �-�-��r,� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Arry earth movemerit may require <br /> �ACWD revtew 8�permits <br /> ��oor(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair �;Storm Damage 18202 Minnetanka Blvd <br /> , Deephaven, MN 55391 ! <br /> ❑ Siding ❑ Restoratian �G]Other. (specify) Phone: 952-471-0590 <br /> , Fax: 952-471-Q662 <br /> Re-roof Q Fre Damage www.m+nnehahacreek.ora <br /> Overall Prvject Description: <br /> Estimated Constructian Valuation of Project(excEuding land) S �� a � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> . Certifies tt�at lhe information supplied is true and correct to the �est of hisJher knowledge. The applicant recognizes that they <br /> are solely responsibte for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to rejeet it un�l it is eomplete; <br /> . Some or ali af the informatlo�that you are asked io provide on this applicedan is dassified by State law as eitfier private or <br /> con6de�aE. Private data Es ir�formation which generally cannot be glve� to tl�e publiC but can be given to tl�e subject of tt�e <br /> data. Confidential data is infnrmation which generally cannot be given to either the pub(ic or the subject of the data. Our <br /> purpose and intended use af this �r�ormation is to annually update our records and re�ords of other govemmer�tat agencies <br /> uired b law. lf u re�use to su I the information the licatiom m �ot t�e issued. <br /> licant's Si nature: �i'-•�L� ' date: / �/✓L �`�/�/ <br /> �PP 9 <br /> E i , <br /> LastUpdated: 05-04-20D9 ' <br /> 6'd b869bLZOZ£ ��� 6ui�ooy �S e95�6 6 06 66��0 <br />