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, <br /> �o`���� City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: � _ ��9a <br /> O�,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �D OJ Dg <br /> a �,`�,. a, Street Address: Received by: <br /> �, ' �ti`S' 2750 Kelley Parkway Plan review fee: � �. <br /> L�E3H��`'� Orono, MN 55356 ��Q _� <br /> Total Fee:� �a7 � <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. (P/ease print) <br /> GENERAL INFORMATION: � A <br /> JobSiteAddress: S�o� QP��2.1� �iJE �(Zph(O /��[�l �JS?J5'� <br /> Will this be a Parade of Homes, Remodelers Showcase H me or other Display Home? ❑ Yes No <br /> If yes,a specia/event permit is required with Police Department and City Council approva/60 days prror to the event. Shutt/e bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner �c��oie o�,e� <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �E�LI�� �t2�STH0 L�T <br /> Phone(day): — — <br /> Address: R Ci : $ "TdV �wVG�LIP: ��g10 <br /> Email and/or Fax _ DC�Y'2 S cGD L�l�. ' �V <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> �Door(s) �Remodel MCWD review 8�permits <br /> ❑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 /> ❑ Re-roof Fax: 952-471-0682 <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: �Z.F,,MopEL k�TtNEN pILYI�t/A�L.� QG�,SEMENT (,/�C W/,V,j�(,�/S �-CC, <br /> Estimated Construction Valuation of Project(excluding land) $ �2 Q U O, O O <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 ref se to su I the information, the a lication ma not be issued. <br /> � � <br /> ApplicanYs Signature: � Date: �GT. g� 2�� <br /> Last Updated: 05-04-2009 <br />