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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: �Q/d—�/8'� <br /> �,�� PO Box 66 Permit number: <br /> ' Crystal Bay, MN 55323-0066 Date received: O/ /D <br /> � F�, �� <br /> r �� Received by: <br /> a � ���, �,�� StreetAddress: <br /> �'�c,t �' ��ti 2750 Kelley Parkway Plan review fee: - - <br /> `�kEsxo� 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: l Z � L�, fv� �-z�-P <br /> Will this be a Parade of Homes, Remo elers Showcase Home or other Display Home? ❑ Yes B.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 /> CONTRACTOR/APPLICANT INFORMATIO : <br /> Name: S� ,� � ; , <br /> State License# 2p Expiration Date: � i t� <br /> Phone: �, �.o -Z office cell <br /> Mailing Address: //�{ . Cit : l a� ZIP: s <br /> Contact Person: Q Applicant is: Contr ctor / Homeowner (Circle One) <br /> Email and/or Fax: rvt� [�.�„��a_� � ►'1� S ; b�; (� ,y�,�, , c c� M <br /> PROPERTY OWNER INFORMATION: /� , I <br /> Name: .{-��—�a.,.� ct,�.�tS� M ar-�: � [`Y�� 6-,-� <br /> Phone (day): 'Z , Z Z <br /> Address: 2 �. Ci : ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> [k�Door(s) �J 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:.�,p�,�,�o �--c ra�� ` <br /> Estimated Construction Valuation of Project(excl ding land) $ y9�p � <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 /> re uired b law. If ou refuse to su I th � formation, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: 3�r`7 i a <br /> �Q�;� � �� ����Q� <br /> Last Updated: 05-04-2009 <br />