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. <br /> - � City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Perrnit number: ' <br /> O��,�.0 PO Box 66 ,: y <br /> Crystal Bay, MN 55323-0066 ,aate'.reCeiVed;' , <br /> a �, Street Address: ���4��bY� r <br /> �'�, Gtiti 2750 Kelley Parkway Plan revi�vv fe8: <br /> ��ESHO�`'� Orono, MN 55356 <br /> ��t8���: � <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: ��� ,��Q� ���-�� /� ��� � ,�5�S!f <br /> Will this be a Parade of Homes, Remodelers Showcase H e or other Display Home? Yes No <br /> If yes,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 s�cient on-site parking is available. Non-permitted events wili not be allowed. <br /> CONTRACTOR/APPLICANT INf�ORMATION; <br /> Name: /"� /�- r �! <br /> State License# Expiration Date: p <br /> Phone: -o? � - office cell <br /> Mailing Address: Cit : ,- ZIP: � <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: t - ' <br /> PROPERTY OWNER FORMATION: <br /> Name: �tl� � . Q ,C <br /> Phone(day): ( - -. S <br /> Address: �p '�� Cit : � .c ZIP: ,s�,.s"� <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 Pro'ect Description: ar YC- � <br /> Estimated Construction Valuation of Project(excluding land) $ , " - OQ <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 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 /> ApplicanYs Signature: Date: / /7/� <br /> -T <br /> Last Updated: 05-04-2009 <br />