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. . City of Orono Building Permit Application Mailing Addr+ess: Pertnit number: �0/D -Gb 3 g 3 �'�� PO Box 66 � � Crystal Bay,MN 55323-0066 Date received: S �.? J d Street Addriess: Received by: � S � ti 2750 Kelley Parkway G~ Orono,MN 55356 Plan review fee: �� %� r��,�og� , -- Fax: 952-249�1616 www.ci.orono.mn.us Total Fee: 25 �a Main: 952-249-4600 This application form must be completed in full and all required informafion must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: Old Bowling Alley �423 Shoreline Dr., 55391 Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes XX� No If yes,a special event pem►it is requiied with Police Department and City Council approva!60 days prior to the event. Shuttle bus se►vice will be requiied unless applicant demarstrates sufficient on-site parking is available. Non-pem►itted events will Rot be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: Fireworks, Freedom&Fun State License# Expiration Date: Phone: 763-442-7676 (office) (cell) Mailing Address: 3806 Gables Court City: Eau Claire WI ZIP:54701 Contact Person: Quentin Nelson Applicant is: Contractor / Homeowner �c�r��or�e► Emait and/or Fa�c: Quentnelson(a�qmail.com PROPERTY OWNER INFORMATION: Name: �r Phone(day): (v - D �� l 6 I Address: �� Ci : � ZIP: Email and/or Fax PROJECT INFORMATION: Type of Projec� My earth movement may require ❑Door(s) ❑ Remodel MCWD review 8 permits ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑wndow(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55391 ❑Siding ❑Restoration XD Other: (specify) Phone: 952�71-0590 tent Fax: 952-471-0682 ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq Overall Project Description: Estimated Construction Valuation of Project(excluding land) �.00 APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • CeRifies that the information supplied is true and correct to the best of his/her knowledge. The applicarrt recognizes that they are solely responsible for submitting a complete application being aware that upo�failure to do so, the staff has no altemative but to reject it urrtil it is complete; � Some or all of the information that you are asked to provide on this application is Gassfied by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annuafly update our records and records of other governmental agencies required by law. If you refuse to supply the i mation,the application may not be issued. �,,. Applicant's Signature: r-�%� ��--_ �- 25_� 0