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� � Cit of Orono �� J Y Building Permit Appiication for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number. / — �d7 l� � Og,O,�O PO Box 66 �` Crystal Bay, MN 55323-0066 Date received: � a �� s, Street Address: Received by: �; ��'�, ' ^'�� ti�' 2750 Kelfey Parkway Plan review fee: � t�ESHo4� Orono, MN 55356 �/ I �� ; Total Fee: �/ � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. fncompfete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: ��7 7�� C� �u� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No !f yes, a specra/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permitted events will not be allowed. � �:c CONTRACTOR/APPLICANT INFORMATION: Name: ��Cl�i�O— ��yS��`:��s� �s� ( �. ;, State License# ��) � ��,�, -<;J Expiration Date: �,3 tY Lead Certification Number. Expiration Date: `' (for work on homes fhat were constructed prior to 1978 � Phone: `P�� — �/ 7/- �C`� �S �office) � �-� — .5�� - �y 7 7 (cell) � � MaifingAddress: ,��)�� y�ch l� )v �� City: _5��,��,.;�,� ZIP: �;-��3� � Contact Person: 6�`�� App(icant is: �tract� / Homeowner (Circle One) � Email and/or Fax: �� ;>� .__ J 7 �, � .�; . � PROPERTY OWNER INFORMATION: � Name: C t�c��y � � S o � -; � Phone (day): �)a- .�.� _,�,�'y l Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require `';i ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: ;� Minnehaha Creek Watershed District(MCWD) �s! ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 � P hone: 952-471-0590 � � (�`Re-roof ❑ Fire Damage Fax: 952-471-0682 ;, ��' www.minnehahacreek.orq a i Overall Project Description: �y c,:(� � � �_` 5 `� � stimated Construction Vafuation of Project (excluding land) $ ��7 C�C� � " z � � APPLICANT ACKNOWLEDGEMENT: - • Agrees to provide all information required or requested by the Building Department; � • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The app(icant recognizes that they '�_ are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative �, but to reject it until it is compfete; � ;� • Some or all of the information that you are asked to provide on this application is classified by State taw 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 the 'y`� data. Confidential data is information wh' h generally c nnot be giv to either the public or the subject of the data. Our � purpose and intended use of this i form ' n is to a nu Ily update r records d records of other governmental agencies i:� re uired b iaw. If ou refuse to su I t informati e a ficafi ma not b issued. � ApplicanYs Signature: Date: �-= � ^ �f LastUpdated: 03-01-2011