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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 /> �,0 PO Box 66 <br /> 0 Crystal Bay, MN 55323-0066 Date received: / /0 <br /> a {�, .- �� Street Address: <br /> Received by: <br /> `. - Gtiti 2750 Kelley Parkway Plan review fe <br /> t9xESH0¢� Orono, MN 55356 <br /> ee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total F ?NQS 3.39 <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: j' <br /> Job Site Address: �Qs5 int U L('y's+AA Rm (2LA <br /> Will this be a Parade of Homes, Remodelers Showcase Home or dther 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/APP (CANT INFORMATION: <br /> Name: a1M�r i1�1' i - C_oy►s t-ru }ion Co t- / 4�� b/u19�' <br /> State License# Expiration Date.- <br /> Phone: <br /> ate:Phone: -77 - Z 16 -%Q3(o-7 (office) - 7040- *00/ (cell) <br /> Mailing Address: jS/ 12d Cit A_( ZIP:P573-74V' <br /> Contact Person: Lq 14e Applicant is: ac or Homeowner (Circle One) <br /> Email and/or Fax: � - <br /> PROPERTY OWNER INFORMATION: _ <br /> Name: C)J2C* -V Pu)b jl L &441 OD1S ��� 2;7g <br /> Phone (day): _ fi� _ 543 14 <br /> Address: bS5 Cry' }.may l Saci " N City: ZIP:557.3 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) E] Remodel ElWater 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.org <br /> Overall Project Description: S ((I+ a oitJ tol'2AY t SaXfP6f19 <br /> Estimated Construction Valuation of Project(excluding land) •-1ZQ .5ZG . do <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 hisihar kn-Allorino. The applicant recognizes that they <br /> are solely responsible for submitting a complete app to do so, the staff has no alternative <br /> but to reject it until it is complete; DoL, C3 ie <br /> • Some or all of the information that you are asked t( fied by State law as either private or <br /> confidential. Private data is information which gene I �© —S Lit can be given to the subject of the <br /> data. Confidential data is information which gener< / blic or the subject of the data. Our <br /> purpose and intended use of this information is to < C,Odd )rds of other governmental agencies <br /> required by law. If you refuse to supply the informatic01 <br /> s y C t <br /> Applicant's Signature: „a«. (®l/ <br /> Last Updated: 05-04-2009 <br />