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, <br /> . City of �rono <br /> . � Building Permit Application d.� .�..� ts� <br /> '�Q\1�,. Mailing Address: Permit number: ���� <br /> ��' '�V PO Box 66 Date received: <br /> � �� Crystal Bay, MN 55323-0066 <br /> f�. Street Address: Received by: <br /> a,� y ��� ti�,/' 2750 Kelley Parkway <br /> \�`',� �oj/ Orono, MN 55356 Pfan review fee� <br /> `��kEsfl���'`-% <br /> \i �/ �� �� <br /> Main: 952-249-4600 <br /> Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: , <br /> This applicatian form must be completed in full and aEl required infarmation must be submitted. <br /> Incomplete applications wilf be returned. (Please print) <br /> GENERAL INFORMATION: <br /> ,1ob Site Address: Old Bawlin Alle - 3423 Shoreline br., 55391 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> /f yes, a special event permit is required with Police Deparfinent and City Council approva160 days prior to the event. Shuttle bus service will be <br /> required unless appficant demonstrates su�cient on-site parking is available. Non-permitted events wi!l not be ellowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Fireworks, Freedom & Fun <br /> State License# 3 �p3b Expiration Date: ,�,,,(� 3�s' 2eo9' <br /> Phone: (office) (cell) 763-442-7676 <br /> Mailing Address: 3806 Gables Court City: Eau Claire WI <br /> ZIP:54701 <br /> Contact Person: Jordan Ruzicka Applicant is: ontr / Homeowner (Circle One) <br /> Email and/or Fax: jordanruzicka@hotmail.com <br /> PROPERTY OWNER ENFORMATION: <br /> Name: Sadia Punjani (Property Manager� <br /> Phone (day): 612-490-9161 <br /> Address: 34321 Myrtle Lane Union City City: CA ZIP: 94587 <br /> Email and/or Fax spunjani@aol.com <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑ Siding ❑ Restoration �her: (specify) Phone: 952-471-0590 <br /> ten� Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Praject Description: <br /> Estimated Construction Valuation of Project(excluding land) $0.00 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Oepartment; <br /> • Certifies that the inforrnation supplied is true and correct to the best of his/her knowledge. Ths applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complete; <br /> `—� Some or all of the infonnation that you are asked to provide on this app[ication is classified by State law as either private or <br /> confidential. Private data is information which generalfy cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> required by law. If yau refuse to supply the i rmation,the application may not be issued. <br /> ApplicanYs Signature: <br /> Date: � oa�f <br />