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, �'1 �� aa`� • � - Cit of Orono f � r `�� Y .��. . �,� Building Permit Application for Internal Work �� (windows, doors, siding, re-roof, etc.) �� j' Mailing Address: � �� ir g,�,� PO Box 66 Permit number: �C�/ `('C�,� � � i � O Crystal Bay, MN 55323-0066 Date received: �� i �e� � � a ��4,;�. s, Street Address: Received by: � I �'�n � �;"'�, �� 2750 Kelley Parkway Plan review fee: �kESH04'� Orono, MN 55356 • � ---- Total Fee: � �� /� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) I GENERAL INFORMATION: � Job Site Address: � �C� ��l �✓� �. `� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes °� 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 §� required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. r.� CONTRACTOR/APPLICANT INFORMATION: � �� Name: � '�(�� g�.� 4 State License# ZO 6 3(S7 Expiration Date: ,"�' � Lead Certification Number. Expiration Date: � (for work on homes that were constructed prior to 1978 �� <�� Phone: `76 • '7 � - � 7�� (office) � cell � ( ) � Mailing Address: s�ys �" J.S� , �, d City: � � ZIP: �_� �g, ; � Contact Person: ��.� Applicant is: Contractor Homeowner (Circle One) Email and/or Fax: '�� ,cf�9 _`�� ' PROPERTY OWNE�R INFORMAT�ON: � "� � Name: �� l � � Phone (day): �js'� � y� _ ��(�,6 � � Address: �� g� ��,( �,�'� (� � City: C7(�-flfJ� ZIP: � ; Email and/or Fax � ' �� ��! PROJECT INFORMATION: �� ;i Type of Project: Any earth movement may require � MCWD review& permits: � � ❑ Door(s) ❑ Remodel ❑Water Damage M Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd s° ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 Phone: 952-471-0590 Re-roof ❑ Fire Damage Fax: 952-471-0682 � www.minnehahacreek.orq � Overall Project Description: = � Estimated Construction Valuation of Project(excluding land) $ L� '� O. — � y � '�- APPLICANT ACKNOWLEDGEMENT: � • 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; �� • Some or all of the information that you are asked to provide on this application is classified by State law as either private or r confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �'�� data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our '� purpose and intended use of this information is to annually update our records and records of other governmental agencies �� re uired b law. If o efuse�o su I the inf ma ion,the a lication ma not be issued. �,� ,. �� " �O `�� ApplicanYs Signature: ��' Y Date: �. Last Updated: 03-01-2011 � _ _ . _ . _ __ ;�