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. City of Orono <br /> • Buiiding Permit Application for fnternal Woric <br /> ' (wl�dows� doors, sidin , re-roof, etc.) <br /> MMidn�Add►�ss: Permit number: G — C/ <br /> O�.O�O ao s�ss .� � <br /> Cryatal Bay,MN 55323-Op66 Date received: <br /> � Srreet nddr,as8: ��Dy: <br /> � 2750 Kelley Parkw�ay Plan review fee: <br /> Orono,MN 55356 <br /> Total Fee: /D�Q�j'� <br /> Meln_ 952 248-4600 Fax: 852-249-4816 www,ci.orono.mn.us <br /> Thls appQcstlon fomn must be complebed In fuN and all required informstlon must be submitbed. <br /> Incomplete applicaqons wlll be r+eturned. (P/ease pHnt) <br /> GENERAL INFORMATION: /'� �C'�,� G r �- <br /> Job Slee Address: t0 v/�,� <br /> YYIII�Is be a Parade af Homes,Romodels�Showcase Home or otAer Display Home? Yss No <br /> N�a 8perara►event pe►m!t!s reyudsd wad,Po�o9 Gepe.anent era chy cowx�V ay�crel Bo d�aya priar ro d,s eire„t Shud►e bus�ervk�e wiw ba <br /> re�d unMss e�ppfloant dernonsbetea suflFcie�on.slbs paddng l8 ev6�9We. A�n�penrdrtsd eirent8 w�!not be allorved. <br /> CONTRACTOR/APPUC�T INFORMATION; <br /> Nsme: /rI�/�Wlb� leoa�, 5�0�/ l✓��0� LnC <br /> State lfoense# :Z DD/p a 7? Expiration Date: p3/3'� �O�� <br /> Lead Certiflcadon Number. Expiration Dete: <br /> (Ihr work�hames fihhat oonsauc� bo 1�Td <br /> it <br /> Phone: 76 3� 7'q G d c�n�� 76 3-�1 Q— I 3 a� c�m <br /> Mailing Address: S' �`�' City: �'e �v�: 7JP: S 3 6 R' <br /> Confact Person: �pnr�y��.�ol�G•� Applicairt is: n cto� / Homeo�wner �cu,oi.on.� <br /> Email and/o�Fex: ')6� -. y �7—400� <br /> PR�PERTY OWNER INFORMATION: <br /> Name: Q�"e'rI �l� <br /> Phone(day): <br /> �cwress: �q # rr, city: ziP� <br /> Emall and/ar Fax <br /> PROJECT INFORMATI�N: <br /> Type of ProJect: My�rfh mareme�t may requin <br /> � ❑Door(s) ❑Remode� ❑Weber Demsge , MCWD�vlew 6 psrmlt�: <br /> Minnehahs Creek We�rshed District(MCWp) <br /> ❑Wincbw(s) ❑Repeir ❑Stcrm Dsmstye 18202 Minnetonka BNd <br /> D swing p�ro�o� ❑oa,er.�sp�ry� o��.MN 55391 <br /> Phone: 852�71-0590 <br /> ❑Fne Dan►aga Fax: 952�71-0662 <br /> w��uv ,_minnehahacreek.or� <br /> Oversll P sct Osscription: "� <br /> Es�mabd Cons�Valuation of ProJect�excluding land) i (ca0� <br /> APPLICANT ACKNCWLEDGEMENT: <br /> A�tees to provfde all(r�nrmadon required or requosfed by fhe Bullding Departmer� � <br /> CeNibs that Ihe Infnnr�ation supplied is true and comect 6o the best of hlslher knawledpe. The appliceM�ecognizes that ihey <br /> are solely responsible for submitting e compbte eppllcadon being aware thet upon fa�ure to do so,the staff has no altema tive <br /> but to roJect it untN It Is complEte; <br /> Some or all of the Ir�fonnadon that you are asked to provido on thia epplk;atlon is dassfied by Stat� lew as ehher privats or <br /> confiderdial. Private date is ir�iOrmetlon whld�generarr cannot be given �the pubfle but can be gnren to the subJect of Che <br /> dete. ConAdentl8l data is inbrma� which generaqy cennot be given o0 oflher the public or tl�e subJect of tl�e dsts. Our <br /> purposa and i�anded use of thls IMormatlon is bo annualty updete our reoords and records of other govemmenml agencie�s <br /> uired b law. If re(use to tl'ie iMocmetlon Ihe ' 6on ma not be issued. <br /> Appllc8►�Ys Signature: Dete: �S <br /> �-t/ <br /> last Updated: 03-01-2011 <br />