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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) C <br /> Mailing Address: Permit number: ,,. _,0/O"0/// S <br /> g,0,,. PO Box 66 <br /> 0 O Crystal Bay, MN 55323-0066 Date received: //7(O //D <br /> Received by: <br /> T / <br /> ,a , : r1� �, Street Address: <br /> 'S.1 r'\441N* <br /> ' 2750 Kelley Parkway Plan review fee. <br /> t <br /> 1t;,►h"1 G Orono, MN 55356 <br /> ESH04• <br /> � <br /> Total Fee: 45—pj .61D <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: 05-- �- id) ____. ' <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: 1 L.1 6e• -v- ii T /l. ..C-7 ,42e /,- <br /> State License# '206 ? g 77-9 Expiration Date: 3/3// .0/.2- <br /> Phone: o/2 9b'6"SG/O (office) ‘/2 '7a'' 56/O (cell) <br /> Mailing Address: 65-63 -'C h.,2e et'• City: Atz- -/, 6,-v,, ZIP: s 5 1// <br /> Contact Person: /5i 944wn .rv,`soh Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: /76 5 7-7/e. STorJ e e h.964f //.e:4, <br /> PROPERTY OWNER INFORMATION: <br /> Name: Alc a./y. i2 //////e <br /> Phone (day): O <br /> Address: acs- orch�z,,d ,a7-,C �efeW City: /�`de ZIP: 3-S-3 sZ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review& permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> � Minnehaha Creek Watershed District(MCWD) <br /> dWindow(s) Ll Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding LI Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: :,j f'A i.2 Lu,m..4.._ ._ PAk_:;,yc <br /> Estimated Construction Valuation of Project(excluding land) $ `S�-7S V <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 /> required by law. If you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: `V--- e mat f-P-7-4-- Date: // --/6 — -2,-,id. <br /> Last Updated: 05-04-2009 <br />