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� , . <br /> City of Orono <br /> Building Permit Application <br /> Mailing Address: Permit number: <br /> Ogr�,�j•O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a� ,� a. Street Address: Received by: <br /> �',�, � G��' 2750 Kelley Parkway Plan review fee: <br /> t•�Esxog,� 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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �; , <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Hom ? 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 will be <br /> required unless applicant demonstrates s�cient on-site parking is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: � <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One� <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: -S <br /> Phone(day): �- — <br /> Address: Cit : ZIP: <br /> Email and/or Fax ,S <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require � <br /> MCWD review 8 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 ❑ 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 s � � � S� <br /> Estimated Construction Valuation of Project(excluding land) $ ?�D D , �D <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,th a lication ma not be issued. <br /> Applicant's Signature: Date: 3--g-6� <br /> Owner's Signature: Date: � --�—() �'j <br /> � <br />