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1J"� <br /> City of Orono �,�, ��,a�r� <br /> � � Buiiding Permit Appfication for fnternai Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �O� MaitiPO Bo�r66. Permit number: /D–L�oZd <br /> O O Crystai Bay, MN 55323-0066 Date received: '� !d <br /> a �;,`i;, a, StreetAddress: Received by: <br /> '�,�, ` Gtiti 2750 Kelley Parkway Plan review fee� <br /> 'Zyx�H�ts,� Orono, MN 55356 <br /> —� Total Fee: � d 7�, f� <br /> Main: 952-249-4600 Fax: 952-249-4616 www ci orono.mn.us J <br /> This application form must be completed in full and a{I required information must be submitted. <br /> tncomplete applications viritt be returned. (Pfease pririt) <br /> GENERAL INFORMATION: ,, <br /> Job Site Address: �.�fU a� ,4 �` � - �.^.� -�2 � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a specia/event permit is iequired with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wil/ e <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Narne: <br /> State License# Expiration Date: g�., � .�,,,�i/ <br /> Phone: � " _ � c>-- � " o�ce �-- v�S�� ^ / cell <br /> Mailing Address: � �� c c /� C� : ,.7 � ZIP: .Ss' � <br /> Contact Person: , ✓ � t � Applicant is: " Contract / Homeowner (Circle One) <br /> Email an�or Fax: �,,,, •„ R q�,,,.. /�� . �o •— - ' �- �� � Cs <br /> NaOe ERTY OWNER JAf�ORMATIOy: ��J // <br /> ( ^ �-�d��' .z,e� <br /> Phone(day): � - �� 8 . <br /> Address: /G G� o�� �!<��- �c C�Y: �^� �;� Z1P:sSJ 6 <br /> Email and/or Fax �,''�-- �-C.J�,�//.c.�=.-. .�- aL- D -*-a <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�pertnits <br /> ❑Door(s) ,�Retnodel ❑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: � �,� � f c%.Yru� � <br /> Estimated Construction Valuation of Project(excluding iand) S ��,GpU'�,�'� <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 comptete application being aware that upon failure to do so, the staff has no altemative <br /> but to rejed it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is Gassified 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 qnnot 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 /> r uired b law. If ou refuse to Su I the information,the a lication ma no#be issued. <br /> r : Date: � :� ��L� <br /> A"hCant's Signatu e <br /> Last Updated: 05-04-2009 <br />