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City of Orono � � Building Permit Application for Internal Work ' {windows, doors, siding, re-roof, etc.) Mailing Address: permit number. ��.¢,0,�. PO Box 66 j Crystal Bay,MN 55323-0066 Date received: �( ��£.>,: � �� t�, �;� �, StreetAddress: Received by: \,�,t„�,�'��,�� ti`�' 2750 Kelley Pa►tcway Plan review fee: ,,\xESH�// 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 t�e returned_ (Please print) GENERAL INFORMATION: � � �� . Job Site Address: `��- Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes No If yes,a special event permit is required wiH►Police Deparbnent and City Co�dl approval 60 days prror to the everrt. Shuttle bus senrice wi1!be required unless applicant demonstrates�cient on site parking is available. Non�oermitted ever►ts wdl not be allowed. CONTRACTOR/APP IC NT INFORMATION: Name: �� r....: 4.a�.w. C �A�2�: h g �.n��r�tc-��t�1 State License# ,��,3 y��y Expiration Date: 3 � 2a 13 Lead Certification Number. (�( ��-_ �O�D�'�- � Expiration Date: �` (for work on homes that were ons ucted prior to 1978 Phone: a1 le- S I3 ,c r0�office) (o(� $"�-�- �2.D0 (cell) Mailing Address: t Z � City: rc.��.�ZIP: (� Contact Person: Q� ,�. �,_ y�� Applicant is: Contractor Homeowner �ci►�ie o�� Email andlorFax: Pa � �-��Q�� Co�s-�rvc^s-` n ar+� PROPERTY OWNER INFORM�TIpN: Name: ��- (�1.�,,,�,- Phone (day): � y - � Address: p r,ry� �� City: f ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(s) ❑Remodel ❑Water Damage MCWD review 8 permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑Restoration ❑Other. (specify) Deephaven,MN 55391 Phone: 952-471-0590 �Re-roof ❑Fire Damage Fax: 952-471-0682 wvvw.minnehahacreek.ora Overall Project Description: -�ea� � � (Z.Q Estimated Construction Valuation of Project(excluding land) $ �t>a� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . Certifies that the infortna6on supplied is true and correct to the best of his/her knowl�ge. The applicant recognizes that they are solely responsible for submit6ng a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classfied by State law as either private or confidential. P�vate 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 wtiich 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 govemmental agencies re uired b law. If ou refuse to su I the inf ation,the a lication ma not be issued. ApplicanYs Signature: � Date: (o Z 1�