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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: �v/d'd� � <br /> �,�,�. PO Box 66 <br /> Q Q Crystal Bay, MN 55323-0066 Date received: �� � <br /> ,� ���N�'"' Received by: <br /> s�`.�� �, Street Address: <br /> �'.�,L �� A" ��ti 2750 Kelley Parkway Plan review fee: <br /> �kESH04 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. (Please print) <br /> GENERAL INFORMATION: / <br /> Job Site Address: ��(cs /��L'�� . �Z�,�� ,�� . <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ 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 ill be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLIC�NT INFORMATION: <br /> Name: R � , ('-e; /La� <br /> State License# 20 Expiration Date: — 2�/ <br /> Phone: � —� office cell <br /> Mailing Address: � ,S Cit : 5�. /Ll�c u ZIP: S''S 3 7 <br /> Contact Person: ;o l� rl �, Applicant is: Contractor / omeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: � <br /> Name: S�IC•� C'A'e'pGVS �LC� <br /> Phone (day): S'Z- Z7o - ��O �1� <br /> Address: .�. 3�� (r,7 City: C��ad� l�c�� ZIP: SS3Z 3 <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.orq <br /> Overall Project Description: �.�,r�,� /,� <br /> Estimated Construction Valuation of Project(excluding land) $ I2, S7S: t}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 i rmation, the a lication ma not be issued. <br /> ApplicanYs Signature: / � Date: '�J �� <br /> / � <br /> / <br /> Last Updated: 05-04-2009 � <br />