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-r�� <br /> City of Orono ab <br /> � Building Permit Application for tnternai Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> Og,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> `; <br /> a � �"9� s.� Street Address: Received by: <br /> �, �� W� GtiF 2750 Kelley Parkway Plan review fee: <br /> �kESH�g'� 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: ,� �pQ � 0.��� Q <br /> Will this be a Parade of Homes, Remodelers Show ase Hom or other Display Home? ❑ Yes �No <br /> If yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be <br /> required un/ess appficant demonstrates su�cient on-site parking is avaifable. Non-permitted events will not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: (XGc�fSV�►P.vi l�btMP ��v1��D1/Pc�,�L►��5, -r1C <br /> State License# �Cj�-7�� Expiration Date: �-,�/-//� <br /> Phone: (?Sl-tf3D-1 3�Ff (office) (celf) <br /> Mailing Address: S'S Ci : ZIP: SS�3S <br /> Contact Person: J�?q,�,� (�,�l;J,� Applicant is: ontractor / Homeowner �c��ae o�e� <br /> Email and/or Fax: �,,� /aS/- �f3� - 3�7p� <br /> PROPERTY OWNER INFQRMATION: <br /> Name: �l � Jl�,�,r�, �P��d' <br /> Phone(daY): 9Sa� �{�l-3�-��> <br /> Address: ��(z� �/p�-i�,��_� City: ��{�"L_ ZIP: ,SS33/ <br /> Emait and/or Fax <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 /> �eephaven, 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: T.��,,t.-D�� �-�'�-vo� h 9�ssL d-�i ati� �0�1��/>.S <br /> Estimated Construction Valuation of Project(excluding land) q�a�'=' <br /> APPLICANT ACKNOWI.EDGEMENT: <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 the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �v'"�"�'' `�� <br /> Last Updated: 05-04-2009 <br />