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' City of Orono Building Permit Application for Internal Work ' (windows, doors, siding, re-roof, etc.) �O� Me1l PO Box 66� Pertnft number. //—DU O O Crystal Bey,MN 55323-0066 Date received: � � Street Address: Received by: 2750 Kelley ParkwaY Plan review fee: Orono,MN 55356 � Total Fee: �� •�� Main: 952-249-4600 Fax: 952-249-d616 www.ci.orono.mn.us This appiicatlon form must be completed in fuil and all required informa�on must be submitted. Incomplete applications will be retumed. (Please print) GENERAL INFORMATION: /� Job Ske/Wdross: �S�u✓1� (�(r�(�C Will this be a Parads of Homes,Remodel�rs ShoMrc.ass Homs or other Dfaplay Home? Yes No N yrs,s spedel e►rent permlt is required w�PoUce Depart�rnent and Clly CounaV approvel 60 days prJar to H�e event Shtdtle bus se�vloe wIN be requJred unless a�pplk�t dsma►atr+ates suMkJeM on�lte perking!s aveHeble. Non-pem�ilted ewsMs w�not be alloweal. CONTRACTOR I APPLICANT INFORMATION: Name: //'1��6✓l S* �ObF��9 ��i 1�1'}►d0� Ln� State Lioense# 2 00�o a �� Expiration Date: p3/3/ a p�a, Lead Cenific�tion Number. Expiration Date: (fbr rwrk on honNs bhat wsro construcl�l prb►t�o 1l78 Phone: 76 3—�l a"? 7-9�.9� (offoe) �76 3 a�80— �.3a � (ce��, MaiUng Address: Sl Car-� � c�v: d� �� Z1P: 3 6 q Contact Person: �pnn�y �J„�4..� Applicant is: / Homeowner �cr�a.o�y Email and/or Fax: ')63 -� y��7� QDO� PROPERTY OYYNER INFORMATION: Name: ��il n;'�P-� �l{�� Phone(day): � ��J A�ddress: �5� .�S-Fc,� �le city: ,� zIP: Email and/or Fau PROJECT INFORMATION: Typa of Project: Any sarth mowmNtt may requlre ❑Doo�(s) ❑Remodel ❑Wster Damage , MCWD roWe�w 8 psrmks: Minnehaha Creek Watershed Dishict(MCWD) ❑Window(s) ❑Repair ❑Stcrtn Damage 18202 NGnnetonka Blvd ❑Siding ❑Restorebon D pther.(speciy) DeePhaven,MN 55391 Phone: 952-471-0590 ❑Re-roof ❑Fire Damage Fax: 952-471-0682 www.m innehahacreek.or4 Overall P ect Desc�iptbn: Estfmated Construction Valuation of Pro excludin Iand i APPLICANT ACKNOWLEDGEMENT: Agrees�provide all inforrnetion required or requested by tlte Building Depertment; CerUfies that tlie iMortnation supplied is true and cornect to the best of his/her knowledge. The appllcarrt recognizes that they are solely r�ponsible for submittlng a comp�te applicatbn being aware that upon failure to do so,the stalf has no altemative but to reject it uMil it is complete: � Some or all of the inforrnatbn that you are asked to provide on this applicatlon is dassified by State law as either private or coMideMial. Private data is infortnatbn which generally cennot be given to the public but can be given to the subject of the data. Confidentlal data is iMoRnatbn wh�h generally cannot be gfven to eitl�er the publk or the sub)ect of the dats. Our purpose and inbended use of this iMortnati�on is to annu�ly update our records and necords of other govemmental agencies uired b Iaw. If u refuee to the i�formatbn the a ' tlon ma not be issued. Applicant's Signature: Date: " [ �a 7 �r� �c upaa�d: 03-o�-za��