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. � <br /> �11/30/2616 13:01 7635356424 GARRY D OLSON PAGE 02 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mading Address: permlt number. � . c�/<,.��-t')/�. <br /> ��,O,�.O Po sox ss .. <br /> C�rystel 13By, MN 553Z3-0�66 DetB fecelYEd: ��+ 'D/ /a' <br /> a� p St►eef Address; Received by: <br /> ��, �dS� aTOo Kelley Parkway Plan reviewfee� <br /> Orono,MN 55356 <br /> Total Fee: ��,�� <br /> Main_ 952-249-4600 FAx: �52-24�J-4B16 vrww.ci.orona.mn.us • . <br /> This application form must be completed in full and all requfred information must e submitted.� <br /> Incomplete appllcatlons wlll be retumed. (Please prirrf) <br /> G�N�RAL INFORMATION: <br /> Job Site Address: ZE e0 Ccv,vl+� Rd b� �on�g �ia�4��M/ .,SS�� <br /> Will this be a Parade af Homes, Remodelers Showcase Home or ather Display Home? Yes No <br /> If yes,a epeclal evenf peimlt Is►aqulred wlth Polloe Daparbr�nt end Gty Coundl approvAl 80 days pdorlo the event Shr�ltle bus aervlce wi/l be <br /> requNod unless eppUcant demonsVafes suH9dont on�lte parMng 1s a�rellable. Non-penMa+ed etire�nts wl!!not be aUowed, <br /> CONTRACTOR/AP I.ICANT INFORMATION: <br /> Name: ��r 0, 0 o,�r � aa <br /> State License# L b33y�1 Expiration Date: 31 !t <br /> Nnone: —'��3' S35�Z 8' office cs �Go-5/a csll <br /> Mailing Address: Ci : C �I fvliv ZIP: ss 2 s <br /> Corrfa�act Person: ,y�, .0 so.✓ Applicar�t is: tractor / Hom�er �c�rr�oon.l <br /> Email andlor Fax; � r ,,,v 5'�S- <br /> PROPERTY OWN�R INFORMA ON� <br /> Name: INn� 3 <br /> Phone(day): ►1�3-085Z <br /> Address: �ce ba� Ci : ZIP: <br /> Email snd/or Fax �� �r ffi <br /> PRGJECT INFORMATION: <br /> Type of Project• Any earth mmremant msy requlre <br /> MCWD terlew d�permlts <br /> ❑Do�Ksj ❑Remodel ❑Weter Damage <br /> Minnehahe Creek Watetshed District(MCWO) <br /> ❑Window(s) (�Repair �Storm Damsge 16202 Minnetonka Blvd <br /> Deaphave�,MN 55391 <br /> ❑Siding ❑Restoration ❑Other.(�pedfy) Phnne: 952-471-0580 <br /> Fax: 952�d71-OB62 <br /> ❑Re-roof ❑Fi►ie Demege www.minnE+il�8119��k ora <br /> Overall Pro ect�escrl on; �.M a �, <br /> Estlmated Constructlon Valuation of ProJect(excluding land) $ 1�7.QDe ob <br /> APP6ICANT ACKNOW4EDGEMENT: <br /> . AprniA�fn�mvirfp all infnrmaN�n�uirF!c!or rPqupat�J hy th�i Building Depa�tmenk <br /> . Certifies that the informatien supplied Is true and corred to the best of hislher knowledge. The applicarrt reoogniaes thet they <br /> are solely responsible for submimng a complete applicetion being ewere that upon failure to do so,the staff has no altemsL1�e <br /> but W re�je�it unt�l it i�s wrt7ple�t�, <br /> � Some or all of the informatlon that you are asked to provlde on this application is dassified by StaN� law as either privete or <br /> confidential. Private data is infarmsbion which g�enerally csnnot be piven to the public but can be given to the suhject of tl�e <br /> data. CoMidentiel data IS fnfom�ativn which generally �annot be given to elther the public or the subJed of the data. Our <br /> purpoee end Intended use oi thls infortnatlon is to annualiy updabe our recor�s and rec4rds oF other govemmental a�qendes <br /> re uir�ed b Isw. If ou refuse to su I Informatl n th a licstion ma not be Iseued. <br /> �!__-- <br /> � <br /> ApPlicanYs Signature: - _ . . .. D�te: o a <br /> last Updated: 05-042008 <br />