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. � City of Orono Building Permit Application for Internai Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: O�,�.0 PO Box 66 � Crystal Bay,MN 55323-0066 Date received: '� - Received by: a Street Address: �,�, '� Gtiti 2750 Kelley ParkwaY Plan review fee: �.��o.$,�v Orono,MN 55356 � Total Fee: Main: 952-249�600 ax: 952-249-461 www.ci.orono.mn.us This application form mus p eted in full and all required information must be submitted. Incomplete applications will be retu�ned. (Please print) GENERAL INFORMATION: Job Site Address: ��j) 1S NUr`�'�► or� • Will this be a Parade o�Homes, Remodeters Showcase Home or other Display Home? Yes o N yes,a speciaf event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events wil!not be albwed. CONTRACTOR/APPLICANT INFORMATIO : Name: "(� ��UVI;1 � G e State License# Expiration Date: 3 Phone: (7�3 �� office cell �'j' Mailing Address: C� 3'` • W S Ci � ZIP: $03� Contact Person: Gt, Applicant is: ontractor / Homeowner �c�i•one� Email and/or Fax: 1� 5(-q�vc7-,34n 1 PROPERTY OWNER INF R TION• Name: Phone(day): - � , Address: ( IV � r1l� Ci : 2 ZIP: Email and/or Fax C � � U�'v"1 PROJECT INFORMATION: Type of Project: Any eartl�movement may require MCWD review 8 permits ❑Door(s) ❑Remodel Water Damage Minnehaha Creek Watershed Distrid(MCWD) �Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55391 (�Siding ❑Restoration ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Re-roof ❑Fire Damage www.minnehahacreek.orq Overall Pro'ect Description: �J `CO iS i't i f� � a ' � [� e Estimated Construction Valuation of Project(excluding land) $ (o ('j 0 (� i�nk APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a c�mplete apptication being aware that upon failure to do so, the staff has no altemative but to reject it until it is�mplete; • Some or all of the information that you are asked to provide on this application is Gassified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of tlie data. Confidential data is inforrnadon which 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 governmental agenaes uired b law. If ou re se to su I the iniormation the a lication ma not be issued. ApplicanYs Signature: � Date: Z"�g'�V Last Updated: 05-04-2009