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�' <br /> City of Orono � <br /> . - � Building Permit Application for Internal Work �{ <br /> (windows, doors, siding, re-roof, etc.) � <br /> Mailing Address: Permit number: <br /> ��,�. PO Box 66 <br /> Q �� O Crystal Bay, MN 55323-0066 Date received: <br /> ,� ��,�-���`, �, Street Address: Received by: �� <br /> ,� ���� <br /> '�' �'� �ti 2750 Kelley Parkway Plan review fee: <br /> � <br /> ��kESH 4'� Orono, MN 55356 <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) <br /> GENERAL INFORMATION:_ � � � ) <br /> Job Site Address: ZZ�1�5 �'iH%Cr�/lL'Y� ��� �`ti � <br /> Will this be a Parade of Homes, Remodelers 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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> i <br /> CONTRACTOR/ PLICANT INFOF�AAT�QN: <br /> Name: ��N��YIJ�'�,� c�h-� <br /> State License# "j Expiration Date: <br /> Phone: �(j -- - �� (office cell <br /> Mailing Address: S J (i.!�S � . �3 Cit : ' � ;�=ZIP: S`;,..i <br /> Contact Person: , Applicant is: ont actor , Homeowner (Circle One) <br /> Email and/or Fax: ' <br /> PROPERTY OWN INFORM TION: <br /> Name: � <br /> ;� Phone (daY)� f�12. ZD.S'— �� � \ S �� <br /> Address: Z2► �c.�r�CT��C�,J (�'�1�. City: � NU ZIP: � <br /> Email and/or Fax <br /> :� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&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: -s`�'L�,' <br /> Estimated Construction Valuation of Project(excluding land) $ �� Z! �'� <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 /> z� <br /> re uired b law. If ou refuse to su I the �nformation,the a lication ma not be issued. � <br /> ___--- •� � <br /> , i � <br /> anYs Signature: �_ Date: �C� ` `/ � ! ,� �� <br /> � <br /> =d: 05-04-2009 ;� <br />