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City of Orono <br /> Building Permit Application <br /> --� Mailing Address: ����� <br /> .g,��J�. PO Box 66 Permit number: <br /> 0 ail O Crystal Bay, MN 55323-0066 Date received: � j <br /> �'���-_ Received b <br /> ,� r ��-�.�� a � Street Address: Y� <br /> �'�,c,t '� °+" � ��! 2750 Kelley Parkway Plan review fee: --'— � �'��— <br /> � l �r� <br /> '�kEsxo4'� Orono, MN 55356 <br /> Total Fee: �) r � J � (n y <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �� � `r I ; ,?, 3 ��� <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: � ���rwo�� � � <br /> Will this be a Parade of Homes, Re odelers 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 b ill be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: __�vi ;� ���1�F_� <br /> State License# Expiration Date: <br /> Phone: l � i C�.� office cell <br /> Mailing Address: Sc� '� r,�l-� w�<1� � � Cit � � ZIP: f <br /> Contact Person: ���� N l� Applicant is: Con ra tor / Homeowner (Circle One) <br /> Email and/or Fax: ,, ',,, � v , -�J <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: `� Cit : ZIP: <br /> Email 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 /> Deephaven, MN 55391 <br /> ❑ Siding ❑ storation ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof Fire Damage www.minnehahacreek.orq <br /> Overall ProjectDescri tion: �-{p�-���, ���e%c. '�r�^/J�,�., /�N �/f� ;�, �'!i��:��-- �,,� <br /> Estimated Construction Valuati n of Project(excluding land) $ /� o��. .-. <br /> APPLICANT 8� OWNER ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department, <br /> • Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize <br /> that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff <br /> has no alternative but to reject it until it is complete. <br /> • The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by <br /> City Staff, consultants or agents, for purposes of investigation of this request. <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: .s-'� � Q � <br /> Owner's Signature: '�' Date: �-� -� `� <br />