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- <br /> �, _ <br /> ��;� <br /> �: <br /> City of Orono - � <br /> � . <br /> � � ` Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> k: <br /> Mailing Address: Permit number: <br /> �v�,� PO Box 66 <br /> Q � O Crystal Bay, MN 55323-0066 Date received: ";' <br /> � ��,�r!,� �, Streef Address: Received by: � <br /> �' '� '�" �ti�' 2750 Kelley Parkway Plan review fee: � <br /> c� <br /> t�'kESH��`'� Orono, MN 55356 ''=� <br /> '', <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: y � � � p `,;� <br /> x� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No x� <br /> If yes, a specral 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 /> �' <br /> CONTRACTOR/AP�ANT INFORMATION: � <br /> Name: L� G�� n ,� �k�r�—� a�,c— <br /> State License# 7����q��� Expiration Date: �?—j�_ �Z �: <br /> Lead Certification Number: Expiration Date: 'rs� <br /> �,� <br /> (for work on homes that were constructed prior to 1978 �� <br /> Phone: �,�z _ �j � ,�j L (office) <br /> (cell) ,� <br /> Mailing Address: ���S • � � City: �� ZIP: 3� 3� <br /> Contact Person: / �y,� / A licant is: ontr / Homeowner ``° <br /> �r l( J�,L•�(Gi� pp _ (Cirde One) � <br /> Email and/or Fax: �� <br /> . �� <br /> PROPERTY OWNER INFORMATION: � <br /> Name: '��° <br /> _� <br /> Phone (day): <br /> Address: 4;� <br /> _3�Yy �C.Jo�L( S�,o.c, <D� citv� ��o�a z�P: <br /> Email and/or Fax � <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require '� <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: ��� <br /> Minnehaha Creek Watershed District(MCWD) � <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 � <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) � <br /> Phone: 952-471-0590 <br /> ,� Re-roof ❑ Fire Damage Fax: 952-471-0682 .,� <br /> www.minnehahacreek.orq <br /> Overall Project Description: �r o u �r��d— o /�-�u�,�, �/�,,� � �Q n„ali� � <br /> �, <br /> Estimated Construction Valuation of Project(excluding land) $ ��� � `" <br /> �. <br /> � APPLICANT ACKNOWLEDGEMENT: 3K <br /> �, <br />� • Agrees to provide all information required or requested by the Building Department; '� <br /> :�� <br /> � <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 info mation is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su the information, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: � �—�/ <br /> �: <br /> Last Updated: 03-01-2011 �� <br /> _�� <br />