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:��� _ �Cj_ �� �� � c�c�� <br /> ' City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: o7.Q/D—O <br /> O�,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: /L oZ�b� <br /> a a, Street Address: Received by: <br /> �, �� 2750 Kelley Parkway Plan review fee: <br /> t��og� Orono,MN 55356 <br /> Total Fee: �/�/n� � �j <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us L��w ��/�-� <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ���8 [�r�,� ;,�,a. iy� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �Tlo <br /> lf yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wil/be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �jc,, 7'"G� �O. G GG� <br /> State License# Expiration Date: /- 0l <br /> Phone: /- � office /- 7�� cell <br /> Mailing Address: y/ }� Ci : ZIP: p <br /> Contact Person: yi, Applicant is: ntract / Homeowner �c�►�ie o�e� <br /> Email and/or Fax: )-, <br /> PROPERTY OWNER INFORMATION: <br /> Name: ! ' <br /> Phone(day): - O - S! �// <br /> Address: Q '�(�. Ci : Q p ZIP: � 6� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: My earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑Remodel Water Damage <br /> �/ Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) p,d Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> y ` Deephaven,MN 55391 <br /> ❑Siding ❑Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Re-roof ❑ Fire Damage www.minnehahacreek.or <br /> Overall Project Description: � ��'f" <br /> Estimated Construction Valuati of Project(exclud ng land) ; � f <br /> i <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all infoRnation required or requested by the Building Department; <br /> • Cert�es 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 altemative <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 class�ed 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 nnually update our rec:ords and records of other governmental agencies <br /> re uired b law. If u refuse to su the inf ion,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �-��''O�10 <br /> Last Updated: 05-04-2009 <br />