2016-00819 - build out interior walls in basement

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City of Orono Building Permit Application for Maintenance / Replacement / Remodel — Residential ONLY (i,e. vvindows; d�ors, sic3in�, re-r�c�f, ��. �- NCJ STRll�TURAL EXP�t��} Mailing Address: � , � �-��A PO Box 66 Permit number. Z(.'��" � ��,�S�'� 7 Crystal Bay, MN 55323-0066 Date received: � - (S�- , Street Address: Received by: �� ' � � �`�:F � ��;I 2750 Kelley Parkway Plan review fee: Orono, MN 55356 �`�f��FS�I-t v��-'� � �-_---�.-- Total Fee: � �� / Main: 952-249-4600 Fax: 952-249-4616 yv��_s^�_ci_rr��.��,i��n.�s J; This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) . GENERAL INFORMATION: Job Site Address: � � � ,e�__t�,P „ Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? ❑ Yes � No /f yes. a special event permit is required with Police Department and Cify Counci/approval 60 days prior to the event. Sh.uftle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wi(1 not be allowed. CQNTRACTOR/APPLICANT INFORMATION: Name: ' State License# Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) (office) Mailing Address: City: ZIP: Contact Person: Applicant is: Contractor / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER IN RMATION: , Name: f}. �i�� Phone (day): �, . � Address: ,e � City: Q ZIP: ss Email and/or Fax: �tjQ�+ �--� �-� __ ____ --- - PROJECT INFORMATION: Overall project description:_ u-� ! //��iC�`!O-+�' Gt� ` Type of Project: Any earth movement may also require , �I � MCWD review&permits: I , ❑ Door(s) emodel • ❑ Fire Damage � ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) I 15320 Minnetonka Blvd � � ❑ Re-roof, ceriar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 � ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 i Fax: 952-471-0682 ❑Window(s) w��%Jv.r-rtinn�h�f��i<�creek.ora Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: I�• Agrees to provide all information required or requested by the Building Department; � • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to � reject it until it is complete; • li • Some or all of the information that you are asked to provide on this application is dassified by State law as either private or i ! confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. I i Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and I intended use of this information is to annually update our records and records of other governmental agencies required by law. If � _ y ouu refuse to supplY the information,the a lication may not be issued _ __ ___ _ _ __ _ ______J Applicant's Signature: � J Date: �_��//� Owner's Signature: Date: Last Updated:January 2016