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. <br /> � � � City of Orono o�`�37 <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: � � Q <br /> �,�,�. PO Box 66 (� <br /> � �.� 0 <br /> Crystal Bay, MN 55323-0066 Date received: % � �� <br /> ,� ��'`'� Received by: <br /> �,;;,, ,, StreetAddress: <br /> '�',�,L9� �'��9�"g �� 2750 Kelley Parkway Plan review fe : <br /> ESHD <br /> � Orono, MN 55356 � <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 3 ,� <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please prinf) <br /> GENERAL INFORMATION: <br /> Job Site Address: ���/6 .�;�,�`-����1�- <br /> Will this be a Parade of Homes, Remodel s Showcase Home or other Display Home? ❑ Yes ,[�'No <br /> lf 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 unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNE INF RMATION: <br /> Name: �- , �� ?� ���c�� <br /> Phone (day): ;/ _ — > ; � <br /> Address: � Cit � ZIP� � � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�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: <br /> Estimated Construction Valuation of Project(excluding land) $ �',�, --- <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 /> � i �/ <br /> ApplicanYs Signature: ��,,;+ . � �i�����"�-��.��� Date: „5��' i�cdld <br /> ✓ <br /> LastUpdated: 05-04-2009 <br />