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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 /> Og,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ,� ����' Received b <br /> ' ,.s�4 a, Street Address: y� <br /> 1��'�n ' '�'� �� 2750 Kelley Parkway Plan review fee: <br /> t�'kESH��`'� Orono, MN 55356 <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. (Please print) <br /> GENERAL INFORMATION: ' / I <br /> Job Site Address: �`I��? �a�-/� 1�v��ve l�/�Uv✓�C� <br /> Will this be a Parade of Homes, Remodelers Show ase Home r other Display Home? ❑ Yes ,0 No <br /> If yes,a special event permit is required with Polrce 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 wil!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: d WN,Qr <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: ���h �d(j� <br /> Phone (day): qS, Z. H'72 ,�� <br /> n � <br /> Address: �c.(C�� (�qr k � ri � City:����� ZIP: S�j ��� <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 /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> �e-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $�� <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 /> re uired b law. If ou refuse to su I infor atio the a lication ma not be issued. <br /> ApplicanYs Signature: � Date: �j��Z(� • ( ( <br /> Last Updated: 03-01-2011 <br />