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City of Orono J y�a <br /> Building Permit Appfication for Internal Work <br /> ' (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permitnumber. � �' �r ���� <br /> O��,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> ��� Received b <br /> ,� -��` � Street Address: y� <br /> x'.F, � v��� �ti 2750 Kelley Parkway Plan review fee: <br /> L�'kESH�g'� 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: � ��� � � �� <br /> Job Site Address: r ��C� (� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wil/be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> Name:RACTOR/APPLICANT INF RMATION: .�/� �Zo� 3 <br /> /- �_ <br /> � QY S ��cMr r`.,.l�S -�� <br /> State License# 203 �g 'T�J'"7 Expiration Dat-�3�sj�2ai-� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior fo 1978 <br /> Phone: "743 `Y2� o�p 3 (office) �/z 6Yk- 023 � (cell) <br /> Mailing Address: ��,3o a p - L n� Cit : ZIP: <br /> Contact Person: ,t�,q�,J Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: aG� ,,�(� �,qys6�r�'arS . co� <br /> . <br /> PROPERTY OWNER INFORMATION: /J ./_ <br /> Name: ��'�(',� �N�-� � <br /> Phone (day): �r Z Y 7 r _ /�( <br /> Address: City: ZIP: <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 8�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 /> 1l'� Phone: 952-471-0590 <br /> [�}-R�-roof 1V ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ /g�'j S�a <br /> � <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 appficant 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 ally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of t�hi ' ation is to nnually update our reco and records of other governmental agencies <br /> re uired b law. If ou refuae'fo su I the in ation,the a fication not be issued. <br /> ApplicanYs Signature: - �!' Date: 7 � 20l� <br /> Last Updated: 03-01-2011 <br />