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JUN-28-2011 07:20 From: To:19522494616 Pa9e:2�2 <br /> City of Orono <br /> 6uilding Pertnit Application for Internal Work <br /> (wlndows, doors, sidi�g, re-rvof, etc.) <br /> Mailing Addness: permit number. I - <br /> O.Q,O,�O PO Box 66 <br /> Crysbl 8ay,MN 55323-0066 Dale received: / <br /> � � Sbeet Address: ��ed by: <br /> 2750 Kelley Parkwey Plan rc�rlew fee: <br /> i���F+ Orono,NAN 55356 <br /> Maln: 952-249-�60� Fax: 952-249-4616 www.ci.orono,mn.us Tats�Fee. / G�/, [�� <br /> l�� T <br /> This application form must be oompleted in full and all requl�ed information must be submitted. <br /> Ineomplete applEcatlans will be retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � � /�9 ��� <br /> Will tbis be a Parade of Homes�Remodele�s owcase Home or othe�Oisplay Home? ❑Yes No <br /> flres,e special event pemv7 es requi�d w�7A Police DepaRment and Ciy Coune�approva160 days prlo�to the everrt. ShutUe bus ' w�l be <br /> r�quired wless appGcairt demonsaates suHPcfent on�ke park(ng is evapable. Non-per►nifted evenGc wa!not be allowed. <br /> CONTRACTOR/APPUCANT INIFORMATION: <br /> Name: 6il/s9D� �GOA�� �/ <br /> S'tate Licens�e# B��.�fp S/� Expiratio�Date: D1�//,� <br /> Lead Certification Number. Explration Date: <br /> (f+ur wv�k on homes that were co�cted prior to 1978 <br /> Phone: �/,a -�/. ��D p (office) (cell) <br /> Mailing Address: / �j� �l,p/ City: � y ZIP: <br /> Contact Person: �gq�/g,g� �;E,rj'W/y Applicar�t is: o�ractor / Horneowner �cr�a o�.� <br /> Email and/or Fax: lp/a� • 5�' (p`p/�' �/g�����s�e� �Oy�fi�yut�s�s,y. �R�1 <br /> PROPERTY O�NNER INFORMATION: <br /> Name: 7�ei'.l� �L✓�'lQ���?� <br /> Phone(day): <br /> Address: �� ��j��,� ,�,� �� 01�d/Ill� ZIP' �"��/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any sarth mavement may require <br /> ❑Ooor(s) ❑Remodel ❑Water Oamage MC���a`pe�m�s: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s} ❑Repair ❑Sbrm Damage 18202 Mnnetonka 8�vd <br /> ❑S�d�ng ❑Restoration ❑Other.(speciiy) Deephave�,MN 55391 <br /> Phone: 952�71-0590 <br /> �te-roo( ❑Fire Damage Fa� 952�71-0682 <br /> www.m i n ne h aha cre e k.org <br /> Overall ProJect Descrfqtion:_y�D¢� $',��—�d� <br /> Estimated Construct;on Valuation of Project(excluding land) a 3s� _ �� <br /> APPI.ICANT ACKNOWLEDGEMENT: <br /> • Agrees to provi0e sll iMotmadon required or requested by the Building Departrnent; <br /> • Certi�es that the informaGon suppGed is we and correct to the best of hisTher knowledge. The applicant recogniies Ihal lhey <br /> �re solely responsible For submitting a oomplete applicativn being aware that upon failure to do so,the staif has no eltemative <br /> bul to reject it unt�l il is complete; <br /> • Some or all of the informa6on tha!you ere e5ke4 to ptovide on this application is dassified by State law as ailher privata or <br /> wnfidential. Private data is infonnaGon ur�fich generslly csnnot be given to Ifie public but can be given to the subJed ot the <br /> dafa. Confidsndai data is infortnadon whicfi generally cannol be given to eiiher the public or the subject of 1he dala. Our <br /> purpose and iMended use of this i�ormaGon is M ennually updete our recOrds end�ecords of olher govemmenlal agencies <br /> re ulred b lew. If u retu 1 ' o alion �e s lication ma no1 be issued. <br /> Applicarrt's Signature: . Date: ������ �/� <br />