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" ��, City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) �O� MailiPg�Bd�Xre�ss: Permit number: �� dG O Q Crystal Bay,MN 55323-0066 Date received: � �� Street Address: Received by: �ti`� 2750 Kelley ParkwaY Plan review fee: ��08� Orono,MN 55356 � Total Fee: /Q,j. ��J' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incompiete applications will be returned. (P/ease print) GENERAL INFORMATION: Job Site Address: Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No ff yes,a specia!ever►t permit is required with Police DepaRment and City Council approval 60 days prior to the event Shutt/e bus servioe will be required uNess applicant demonsbates sutficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: �/ Name: /rl��G✓l��` �omF�h9 ��i,`y l�✓y�►do� LnC State License# ,`Z p p/p a 7 7 Expiration Date: �3/3�O oZ pe� Lead Certification Number: Expiration Date: (for work on homes that were construc�prlor to 1978 Phone: 76 3—�/a� 7-9 G 9(� (office) 76 .3 0�84— /.3a Z (ce11) Mailing Address: (p ,S'/ �Q�-►,pr Cy� City: !l� v�- ZIP: Ssj 6�{ Contact Person: �ryn.�i �P.�b••i Applicant is: on actor / Homeowner �ci��o�� Email and/or Fax: ')63 - �/ �7� JrOD� PROPERTY OWNER INFORMATION: Name: �tc.�c,�� C��c��+ Phone(day): Address: 1 ! (� S�t��,; Sf-E'�t (,��'"C/{ City: ��Z,,�lu,f� ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: My earth movement may require ❑ Door(s) ❑Remodel ❑Water Damage MCWD review 8 permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑Restoration ❑Other:(specify) Deephaven,MN 55391 Phone: 952-471-0590 '�Re-roof ❑Fire Damage Fax: 952-471-0682 www.minnehahacreek.orq Overall Project Description: Estimated Construction Valuation of Project(excluding land) S , �% APP�ICANT ACKNOWLEDGEMENT: Agrees to provide all information required or requested by the Building Department; Certifies that the infomnation supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no aftemative but to reject it until it is complete; . Some or all of the information that you are asked to provide on this application is classfied by State law as either pnvate or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. ConfidenGal data is informatlon which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this infomiation is to annually update our records and rec;ords of other govemmental agencies re uired b law. If ou refuse to su I the information the a lication ma not be issued. ApplicanYs Signature: �"'4v/ � `�-.,�� _ Date: � � r � � Last Updated: 03-01-2011