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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> OMailing BoAddr ss. Permit number: .... 47/D —o00 `t'F( <br /> 0 O Crystal Bay, MN 55323-0066 Date received: c;3/1A O <br /> `" Received by. <br /> � �� ,q�� �, Street Address: <br /> . �, ) Gtiti 2750 Kelley Parkway Plan review fee: <br /> 9k ao¢' Orono, MN 55356 1 <br /> Total Fee: t(�7 Q, -7 <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: <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 <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: • <br /> Name: /3'!l// si 2Er i 2. 0 00,,, 6 , 1-L( <br /> State License# 2 o,c go 6 i 3 Expiration Date: 3-3/- Zol o <br /> Phone: q5-2- 120 -'3o1 (office) (cell) <br /> Mailing Address: 6110 rr7, / S r Ei Ci • - --'- ,-)00.9 ZIP: 53 3/ <br /> . <br /> Contact Person: 6n., -4 PE.y G.G 1/'r Applicant is: Contractor Homeowner (Circle One) <br /> Email and/or Fax: //1//_ 57 '4' m5,-1. c,aN, <br /> PROPERTY OWNER INFORMATION: <br /> Name: 17/9-01 P Cv///45 <br /> Phone (day): 95-7-- 1176 - -796,,/ <br /> Address: /Zd 01704o 6,207/9-a0 Rd City: 612ar7v ZIP: 5-5391 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) g Remodel ❑Water 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 /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: £1,h5a/.9TC fyTEnicA- 41/a//1 /11 5r4// Tr/E 5170 .✓ 411/ //;764- ,ff— ar&at z <br /> Estimated Construction Valuation of Project(excluding land) $ 6 Qbo _" <br /> s <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 /> Z. <br /> but to reject it until it is complete; v <br /> v <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 .4 <br /> purpose and intended use of this information is to annually updat- •ur records and records of other governmental agencies <br /> required by law. If you refuse to supply the information,the appli may not be issued. <br /> , .. _, . -..z.:______,,c. / <br /> Applicant's Signature: 1� Date: 2 — ( /v <br /> Last Updated: 05-04-2009 <br />