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— 3, a�^.-:` �'es'�'•'t ..5��.� v <br /> 4 <br /> _ '4` '� <br /> � � � Cit of Orono �� ��_�`k� 3 <br /> Y y�� <br /> Building Permit Application for Internal Work �� <br /> 5� <br />�. (windows, doors, siding, re-roof, etc.) �� <br />�•: <br /> ��. <br /> _ � ; <br /> Mailing Address: Permit number. ��'— <br />�' ' �v�,� PO Box 66 � <br /> � � „� Q Crystal Bay, MN 55323-0066 Date received: .� /� � <br />"' i -�/� <br /> Received b � <br /> �(�a �'�' �.;' s, Street Address: Y� � /� � <br /> 1 4�,�. / <br /> �'�t���� "'� ���'� 2750 Kelley Parkway Plan reviewfee: /�/ ,� <br /> a �1�`��Sv Orono, MN 55356 �� <br /> kEsxo4' �� �� �„ <br /> -- Total Fee: � <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) �r; <br /> GENERAL INFORMATION: c� p �° <br />�' �� 1� L��� �1n-�cr ���P <br /> Job Site Address: <br /> ; Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No � <br />`�r'' If yes, a specia/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 />.._; ��fi� <br />}ft <br /> CONTRACTOR/APPLICANT INFORMATION: '{ <br /> Name: �' �C�^��/.�l �� C e;`. <br /> State License# �� <br /> Expiration Date: � �' <br /> Phone: �, , ( office , ! ..`� c�g � cell �' <br />��= Mailing Address: Cit : , ZIP: _ �„� <br /> �R, Contact Person: �--- Applicant is: ontracto Homeowner (Circle One) p <br /> Email and/or Fax: ��' <br /> � <br /> f� <br /> PROPERTY OWNER INFORMATIO �n � � <br /> Name: � ,� �'.'� �-��.�� �� <br /> Phone (day): � �rc �� � <br />�'" -� ��=--ra 1�-�i <br /> Address: Cit : ZIP: -� <br /> �` Email andbr Fax r" <br />�.. PROJECT INFORMATION: <br /> � <br /> � Type of Project: Any earth movement may require � <br />�:`�� MCWD review&permits � <br />�x'� ❑ Door(s) ❑ Remodel <br />�,;w ❑Water Damage �� <br />�'' Minnehaha Creek Watershed District(MCWD) <br /> � <br /> e.-' ❑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: � �j� � w �� �C i"t '��J b'� � <br /> ° Estimated Construction Valuation of Project(excluding land) a; p� <br />�.; - <br /> APPLICANT ACKNOWLEDGEMENT: ti <br />� ' • Agrees to provide all information required or requested by the Building Department; � <br /> ,;� <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they s`� <br /> ' are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br />� ° k; <br /> but to reject it until it is complete; <br /> ,�:s <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 />,�<; <br /> Applicant's Signature: ���,, � Date: �J�,v�,.� '"3 — � � <br /> Last Updated: OS-04-2009 <br />� .. .� .. �� _...r..� _J m:�.. � <br />