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� � <br /> , ����-� <br /> City of Orono <br /> Buiiding Permit Applicatlon for Internal Work <br /> ' (windows, doors, sidin , re-roof, etc.) <br /> .�.�,j� ��O BA ox�66� Permit number o�Ul/— �D�7 <br /> Q O Crystel BsY,MN 55323-0088 Dete reoelved: ! <br /> � � Sh9etAddiess: Recelved by: <br /> 2750 Kelley Parkway Plan review fee: <br /> Oronc,MN 55356 <br /> Total Fee: ��5,Q� <br /> Maln: 952 248r{600 Fax: 852 248-4616 w�w.ci.oro�o.mn.us <br /> This application form must be oompleted in full and all required iniormatibn must be submltted. <br /> Incomplete applicatlons wlll bs�med. (Please p�lnt) <br /> GENERAL iNFORMATION� (pS� ��5��� CI%G�� <br /> Job Ska Address: <br /> WIII tlds bs a Parado ot Homes.Remodelsr�s Showcase Home o�other Dfsplay Non�e? Ys� No <br /> �Fr�s.e spedal6�ene a�►�It Is�eq�red►r�r Po�oe Oeperu�nt and ay cour,d epprover p day�s p�r!!nr m d►.ever,r. snume bus se►vice wns Oe <br /> required u��feaa appMce►u damonshetes auAlaent on.�fts parkinp!s ev�7eb/e. Non-penrrlMad events w�►►w[be a�owed. <br /> CONTRACTOR/APPUC�INFORMATION: <br /> Neme: /�1�CYWIb� pb , S'd/ !�✓J�I�C4� Ln� <br /> State License# 2 00�o a �� Expiradon Date: p3/ i �p�.� <br /> Lead Cerd�tlon Number: Expiration Date: <br /> rybr work on homas tlwt wero aan�strue�prfo�r m 1978 <br /> Phone: 76�—�l a"? 7'`��9 6 co��� �6 3�o- I 3,� � c��� <br /> �ung Aad�ess: �� �'t city: P�� v� ziP: 3 q <br /> Cor�ct Person: rrny �lGs4.•� AppllcaM is: n r / Homeowner tcMw o�e� <br /> Emall and/or Fex: 7 6.� -..y�a 7— �00� _,.�,,, <br /> PROPERTY OWNER INFORMATION: <br /> Name: �3�(a (/'ty'a'��� <br /> Phone(day): / <br /> Address: (�S1 ���i��c. GirGf� City��ir(/��'� ZIP: <br /> Emai and/�Fax <br /> PROJECT INFORMATION: <br /> T�Ips of ProJ�et: My earth movemoM may roqufro <br /> � ❑Door(s) p Remodel 0 Water Damage , NCWD rsviwr 3 perndts: <br /> Minnehsha Creek Watershed Dlstrlct(MCWD) <br /> O window{s) ❑Repai� O sto�m Dama�e 18202 Minnetonka 61vd <br /> []Slding ❑R�es�oretlon 0 Other.(spedfY) Oeephaven,MN 55391 <br /> Phone: 952�T1-0590 <br /> .,�'ke-roof ❑Fre Damsge Fax: 852-471-0682 <br /> www.minnehahecreek.orsi <br /> Oversll ProJw:t Qoscri n: <br /> Estimatad Constructlon Valuatlon of ProJect(exduding land) i � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> ligrees b provide all In(ormetion rmquired or requested by tlte Bullding Depenmerrt; <br /> Ce►bfies thai the fMomiatlon supplied is true and oorrect t�Ihe best of hisfier IvwwledDe. The appUcent na��iaes that they <br /> aro sobly respons�le for submltdng a campbte applics4on being swere that upon feilure to do so,the staff has rw alt�mative <br /> but t�reJect It untll it is oompleta; <br /> Some or all of the IMormeti�on that you are ask�ed to provlde on this applicado� is dassilred by State Isw as either privete or <br /> coMidentlal. Private da� is iMormstlon which yenerapy cannot bs given �o the publlc but can be given Lo �e subject of the <br /> data. Cor�ideMial ds� is Iniormetion which yenerady carnot be glrren lo elther the p�lic or the subject af the data. Our <br /> purpose and InOended uso of this ir�om�on is to annually updeta our raoonds end reoords of other govemmenml agendes <br /> ulr�b law. If s the h�Mmnetbn the a ioalion ma rwt be i�ued. <br /> Applk;anYs Signature: DaUe: 'et.l'''�� <br /> Last Updated: 03-01-2011 <br />