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z A� �SC <br /> C i ty of O ro n o ��_��F ��� �� <br /> � w�� �����}°` � <br /> f • Building Permit Application for Internal Work � <br /> (windows, doors, siding, re-roof, etc.) �_� <br /> Mailing Address: � <br /> �,�,� PO Box 66 Permit number: �� <br /> A Q � Q Crystal Bay, MN 55323-0066 Date received: �� <br /> �,�'}��3 � x <br /> � '�' ��-�^� a StreetAddress: Receivedby: � <br /> s �,e.�:,� <br /> �'� 4� '�`� � 2750 Kelle Parkwa �� <br /> � Y Y Plan review fee: �,; <br /> ��kESH04'� Orono, MN 55356 `� <br /> - Total Fee: '^� <br /> Main: J52-249-4600 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. -x <br /> Incomplete applications will be returned. (Please print) �� <br /> GENERAL INFORMATION: � <br /> Job Site Address: ; �5 �v1� �,.���� g��/� � <br /> Will this be a Parade of Homes, Remodeler Showcase Home 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 servic ill e ��' <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ;�f <br /> �: <br /> CONTRACTOR/APPLICA�IT INFORMATIO }� <br /> Name: %�'( ,c�wr�� �az>���_S z� <br /> State License# a6�1 U 7� Expiration Date: � <br /> Phone: _ 7(„3 -- y��-�� �� (office) 7(,j•-��W -(�OY3 (cell) <br /> Mailing Address: .� • s' ca� Q C,t- iti./ Cit : ;�-c�k z ' ,�„c ZIP: S-5" . �' � <br /> Contact Person: �, � S �,;.. A licant is:' Contract r / Homeowner � <br /> " pp (Circle One) <br /> �,� <br /> Email and/or Fax. ,�� � ;..�,` �s.� �(uS _C��� ?� 3�- =(a 7�-�T�l �� <br />::q`,, <br /> ' PROPERTY OWNER INFORMATION: <br /> Name: /��.��r-f-�i S �r F��.�y <br /> Phone (daY)� '���� -L( 7 3 --��o(v� <br />�•, Address: � 44S'fi Lo�<, L,,�e ���� City� "�� L� ,� ZIP� 5�-35�; <br /> Email and/or Fax �' <br /> � <br /> y`, �� <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 /> r ; ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590 <br />'�` Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> . � <br /> 4 Overall Project Description: � �,� � «,�.� y�� - ..L S� �t,�c� �c<l :; c � � <br /> _ Estimated Construction Valuation of Project(excluding land) $ �. � `� <br /> � �� <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; � <br /> e"J <br />. • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> a, are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative � <br /> Y' but to reject it until it is complete; =� <br /> :! N-. <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 tl�is-auformation is to annually update our records and records of other governmental agencies � <br />;_, re uired b law. If ou refus,e�"to su I he infor tion, the a lication ma not be issued. <br /> � � <br /> � <br /> _ ApplicanYs Signature: Date: � /3� � b <br /> _ � <br />� � <br />`° Last Updated: 05-04-2009 <br /> y <br /> 3`.� �, T �"x ��5�� ' <br /> 43 .� G'a"�� '�yY �� <br /> _ . ... . � . _. . , _.. � a- .., _. ,fi�.� ._�LE.W�.� <br />