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� � �o� # 133� �N � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doo�s, siding, re-roof, atc.) <br /> _� Maifir►g Address: PermiC number: '� 9 <br /> ���j:�,. PO 9ox 66 <br /> � ,• Q� Crystal Bay, MN 5532�0066 Dale rocelved: � / � <br /> a <br /> srre��Add�ss: aece�ed ny: <br /> �'�t, � �� �� 2750 Kelley Pa�fcway Plan review fea- <br /> �� � Orono, MN 55358 <br /> ,:,,�c�efvo� 7`! a � <br /> ��-'�- Tolal Fee: <br /> Maln: 952-249-4600 Fax: 852-248-4816 www,ci,orono.mn.us <br /> This application form must be completed in full and all requlred information must be submitted. <br /> Incomplete appllcatlona wlll be returned. (Please print) <br /> GENERAL INFORMATION: �C <br /> Job Slte Address: �� L��. Gv�c.� i� E <br /> Will this be a Parade of Momes, Remodeler5 ShowCase Hvme o�other Display Home? Yes No <br /> 1/yos,e apecls/avent permit is�equired with Police Depe�tment end City Councll approval BO dsys prior ro the ev�nt ShutHa bue sarvice wlll be <br /> �qWrod unleas epplice►rt demonatiates suil7ciant on-site perking Is avallable. Non-permitted events will rrot be allowe0_ <br /> CONTRACTOR! PLICANT INF RM TION: <br /> Name: \ S n <br /> 5tats Lfcense# Expiretion Date: � <br /> Phone: _ office c�ll <br /> Mailing Address: � Ci ; ZIP: <br /> Contact Per6on: � Appticant i r / HomeOwne� IClrol.oe.) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF RM 710 : <br /> Name: <br /> Phone(day): 5 - 0 rr <br /> Address: („ r�, � t Ci : ZIP: �7"J <br /> Email an�/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: Any eartn movement may requlre <br /> ❑ poo�(s) ❑Rematlel MCWD review 8,permlta <br /> ❑Water Damege <br /> ❑Windo s Mlnnehehe Creek Watershed Dlatrict(MCWD) <br /> w( ) ❑ Repair ❑Storm D�mage 'tB202 Minneto�ka Blvd <br /> Q�ephaven, MN 55391 <br /> ❑Siding ❑Restoration ❑Other: (sp�cify) Phone: 952�471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire bamage www.mi e ahacre k,or <br /> Overall Pro ect Descri ion: �,- � <br /> Estlmated Construction Valua�lon of P ct(�cludin land) $ � � <br /> APPLICANT ACKNOWLEDG�MENT: <br /> • Agrees bo provlde all Informetion►equired or reQuesled by the Building Qepartrnent; <br /> • Certifies lhat Ute Infortnatlon supplied is true a�d comect to the best of hls/her knovvledge. The �ppl�ant recognizes�at they <br /> ere Boleiy responsible for swbmitti�g a complete epplication being aware that upon failure to do sa, Ihe staffi has no allemedve <br /> but to rejed Il untll It 16 Complete; <br /> • Snme or all of dte ir�fom�aNati Ihat ycu are asked to provide on thla application is Gasstfled by 3tale law as eilher privats or <br /> oonfldendel. Priv�te dala is infonrtaUon whlch �enerally r,annot be gh►en to the publlc but can be given to the eub]ect of the <br /> deta. Gor�idenGal data Is Iniormetlon wl�ich genarapy cannot be given bo either the puDllc o� the sub�ecl of the data. Our <br /> putpose and Intended use of this infom�aUon Is to annually update our records and reoorde of other govemmentel agenclee <br /> uired law, If u refuse to su Ih�information.the e lc�tion ma not be Issued_ <br /> Applicant's Signature: Date: ` <br /> �a�u��8d: og-a-zoos <br />