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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 /> Og,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: (� � /0 <br /> a ����"' Received by: <br /> s,-�^ s, Street Address: <br /> �'.F, �� 's-;,,� �ti�' 2750 Kelley Parkway Plan review fee: <br /> L9xESH�� 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: ;`,�f(�S A.���1-�5���, � �. �v�. <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 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: l3 . J:�� 1._�...��-c*�,,�z. <br /> State License# — �,,,.,`,z�,.,�„�„_,�.. .— Expiration Date: <br /> Phone: (��� � ��f j' ��[ t3�� (office) (cell) <br /> Mailing Address: �.C�. (3� � �� Cit :C:� ,�-;� �3,�� ZIP: 5 s-3.�- <br /> Contact Person: Jvtr-� Applicant is: Contractor / eowne �c���ieo�e> <br /> Email and/or Fax: j � �N,d,.,a-�c�C V�s ; . LG�`-1 . <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <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.orp <br /> Overall Project Description: �z,,��,�t�_ '�;,«��-�,�tis�, - 1�_1,�+ ��rs�. �.�.�...w�s�s--� �--��o�-��,� <br /> Estimated Construction Valuation of Project(excluding land) $ ro vv� <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 s the information, the a lication ma not be issued. <br /> __- _._ � <br /> Applicant's Signature: A____-----_.._._...___.-----_ Date: :��- C��-iZ,j�,;�� a�' 6 U <br /> Last Updated: 05-04-2009 <br />