Laserfiche WebLink
� � <br /> C i#y of Orono <br /> Building Permit Application for Interna� Vllork <br /> (windows, doors, siding, re-roof, etc.) � � <br /> Meiling Address: <br /> '�fl� PO Box 66 Permit number. O/d-b/dD/ <br /> j Q Q Crystal Bay, MN 55323-0066 Date received: /b��Fl/O <br /> i� �+ Sfreef Address: Received by: <br /> �`% 2750 Kelley Parkway p�� ��eW�e: <br /> �S�o�' Orono,MN 553� � <br /> Main: 952-249-4600 Fax; 952-24�4616 www.ci.orono.mn.us TO��Fee: �S�,�,S <br /> This applicatfon form must be complebed in full and all required infortnation must be submitted. <br /> incamplets applic�tions will 6e returned, (Please prirrt) <br /> GENERAL I�IFORMATI01�: <br /> Jcb Site Address: �D�O s',4�Gfn? �T, pr0�0, mn. SS3SG <br /> Will this be a Parade of Hames, Remodelers Showcase Home o�other Display Home? Yes No <br /> N yes,a specia/eveiM peimit!s requbed wlth Poffce Depadmeirt arni Cify Councfl approva!80 days prror to the everu. Shutfle brrs servlce wiH,be <br /> raquiied unless app/kant demons(rates sufficfent on-site pa�dng ls avallable, Non-peanitie�ol events wNf not be allowieri. <br /> CONTRACZOR 1 APPLICANT INFORMATI�N: _ , . <br /> Name: �/�A/�7� �LDOFIA� G �V TF�oK S ,7,�l� . <br /> State License# ZpG,3 g a, � Expiration Dabe: 3 � �// <br /> Phone: �5/-�48-�oay ot�ce (,a�- toia�63- cen <br /> MaiFing Address: .20 Bo � A S�s� quQ Ci : �ST• �a4` ZIP: S5/1 <br /> Contact Person_ ��eT DSD�,1 Applicarrt is: ntractor 1 Homeowner �c�rc�eone> <br /> Emaif and/or Fax 5/-(9 f -�3G�2g <br /> PROPERTY OWNER 1NFORMATIQN: • <br /> Name: /?obb l�vra. �i,�6Ql� ,(�,�.- <br /> Phone(day): l�Io't- G(e - <br /> Address: �?080 �i►�t Cit . O/r0/70 ZIP: S5.3SG <br /> Email andlor Fax __ ULD Nf�Scy 19 �.o . Lom <br /> PROJECT INFORNIATfON: <br /> Type of Projec� <br /> Any earth movement may require <br /> MCVYD review 8 rmits <br /> ❑Door(s) Q Remodel ❑Water bamage � <br /> ❑Window(s) ❑ Repair ❑Sborm Dam e Minnehaha Creek Watershed District(MCWfl) <br /> 89 '182b2 Minnetonka Blvd <br /> ❑Siding ❑Restoration Deephaven, MN 55391 <br /> ❑ Other. (specify) Phone: 952�71-0590 <br /> Lr1 R�raof Fax: 952-471-0682 <br /> ❑Fire Damage www.minnehahacreek.o�a <br /> Overafl Project Desc�iption: ,Q�o / N�GtJ �'�Ds►-� �NA� �P�IO� <br /> Estimated Construction Valuation of Project(excluding land) $ / p�,�j — <br /> APP�ICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the infnrmation supplied is true and cwrect to the best of his/her knrnMedge. The applicant recognizes that they <br /> are solely responsible for submitting a compJete applicatiors being aware that upon failure t�o do so, the staff has no�tema�ive <br /> but to reject it until it is complete; � <br /> • Some or all of the in�Orma6on �at you are asked to provide on this application is classifled by SNate law as either private ar <br /> confiderrtial. PrivatB data is iMormation which generally cannot be given to the�ublic but can be given to the subject of the <br /> data. Confrdentia� data is inbrtnation which generally csnnot be gi�en to effher the public or the subject af the data. Our <br /> purpose and irriended use of this inimmation Ps to ann�lly update our records arrd reoords of other governmental agenaes <br /> re uired law. If ou refuse to su I the information, the a ication ma not be issued. <br /> ApAlicanYsSignature: � � ��. /�j. �O �O <br /> Oate: <br /> Last Updated: 05-04-200g <br /> Z'd LZSb£6t�699 '�NI N011ldb211 �ZZ�06 06 L6��O <br />