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T" Ci of Orono `�� <br /> . � �� <br /> � Building Perm�t Application for Internal Wo � <br /> ' (windows, doors, siding, re-roof, etc.) <br /> �n�,►�aa�re�: Permit nwnber. �D//-(>�� <br /> O.¢,O,�.O Po eoX ss <br /> crysr�i Bay,nnr��zs-ooss oete re��a: Z <br /> � � Street Adalress: Received by: <br /> 2750 Kelley ParkwaY Plan review fee: <br /> Orono,MN 55356 <br /> �- <br /> Total Fee: /��,�� <br /> Main: 952-249-4600 Fax: 952-24&4616 www.ci.orono.mn.us <br /> This applicatlon form must be completed in full and all required i�ormatbn must be submitted. <br /> Incompletie applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: 5 � �� �-��C(2 <br /> Job Sks A�ddress: <br /> YVfll tl�ls be a Parads of Homes,Remodslsrs Showcass Homs o�other Display Homs? Yes No <br /> N yrs,a sped�ev�nt ps�mlt ts requlred witlr Polke Deparaner�and C1ty CouncA epprova�so days p�ior ro tne ev�ent Shume bus servke wN►ee <br /> req�d�red uMess a�ppNcent cbrrwnabstes suf►ldent w►-s�te ps►king!s available. Non-penr�lted e�wiM rat be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: /�'1��6•/lb�r'- leOb F��9 ���� l�►71d04d Ln C <br /> State License# ;t p p/p a 7 7 Expira�on Date: p3/3� a pt a <br /> Lead Certfication Number: Expirabon Date: <br /> (fbr w�rk on fro►nss that wws construcJryl p�ior b 1l78 <br /> Phone: 76 3—�a"? 7'q r•q� c�� 76 3 a8o- /3� � c��n <br /> MaiNng Address: S' � Cy- City: Q�i vG ZIP: 3(,q <br /> Contact Person: �p�ytiJ� �J„�4.� Applicant is: / Homeowner �cr�a.a»� <br /> Email and/or Fax: 763 — y a7� �DO� <br /> PROPERTY OWNER INFORMATION• <br /> Name: /�'f�c� �vr'��- <br /> Phone(day): � / <br /> Address: (O5� S�C C GI�C City:���l �� ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type oi ProHct: Any�arlh mownwM may require <br /> ❑Door(s) ❑Remodel ❑Weter Damage , M��'°w°�"��`P°��' <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑S�ortn Damape 18202 Minnetonka Blvd <br /> ❑Sidi� ❑Restoretion ❑Other.(spec3fy) �eephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof ❑Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.ors� <br /> Ov�rall Project D�sc�iptfon: <br /> Estlmabd Construcdon Valuatbn of Project(excluding land) S <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all infom�atbn required or requested by the Building DepartmeM; <br /> Cenifies that the ir�ortnatlon suppfled is true and comect to the best of hisfier knowledge. The applicarn recognizes that they <br /> ere solely responsible for submittlng a c�rnpbte applicatbn being awere that upon failure to do so,fhe staff has no altemative <br /> but to reject it uMil it is compbte; <br /> � Some or aN of the Informatbn that you are asked to provide on this applicatbn is dassHied by State law as either prNate or <br /> ooMiderttial. Private data is iMortnatbn which generally cannot be given to the public but can be given to the subject of the <br /> data. Confldentlal data is infortnatlon whk� genereNy cannot be given to efther the public or the subject of the data. Our <br /> purpose and inbended use of this information is to annued our reconds and records of otl�er govemmental agencies <br /> uired b law. If u refuse�o su the informa a ication ma not be issued. <br /> ApplicanYs Signature: Date: � �7 J�r <br /> �upd�d: os-o�-zo�� <br />