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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �,�,�. PO Box 66 <br /> � � O Crystal Bay, MN 55323-0066 Date received: <br /> �� <br /> ,� ' ;�4�' �, Street Address: Received by: <br /> '�'�c, `� "%� �ti� 2750 Kelley Parkway Plan review fee: <br /> ��xESHOg'� 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: � �S� �o� (��� (�_ <br /> Will this be a Parade of'Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �-- <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 sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION• <br /> Name: �3�� <br /> State License# 2p 63i$"1 Expiration Date: <br /> Phone: (,3- �- X'7�� office cell) <br /> Mailing Address: ' � '� D��''�-� S�� -�(� Cit . ZIP: � � ' <br /> Contact Person: Applicant is: ontract . / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �o'� �Vl'}'� L <br /> Phone (day): S� � `1 � � 6� <br /> Address: ,S'� r� 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 ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> e-roof ❑ Fire Damage www.minnehahacreek.orp <br /> Overall Project Description: �-��� <br /> � <br /> Estimated Construction Vatuation of Project(excluding land) $ c�� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <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 /> C <br /> � � j�- � � � <br /> ApplicanYs Signature: Date: <br /> Last Updated: 05-04-2009 <br />