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t Apr. 27. 2011 11 ;40AM Na. 7111 P, 1 r City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) g O� MailiP B�6sGs: Permit number, a��`�D� Q �w0 Grystal Bay, MN 55323-0066 Date received: a ,�'b, a St►eet Add�ess: Received by: m�, � �E�' 2750 Kelley Parkway Plan review fee: ��og6 Orono,MN 55356 �_=' Total Fee: �3�.3 � Main: 952-249�600 Fax: 952-249�1616 www.a.orono.mn.us �� ' This application form must be completed in full and ali requir�d irifonnation must be submitted. . Incomplete applications will be r�etumed. (Please print) GENERAL INFORMATION: ` Job Site Address: 30(p0 (,` oc-�.h� �Cl �O WII this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No N ya�a speaal event permit is�quired with Police Depaitment and Ciry Counal approva160 days prior to the event. ShuCJe bus seivice will De m.quired unless applicant demonstrates suff►cient on-sile padaing is available. Non-per►nitted evenfs will not ba allowed. CON7RAC'rOR/APPLICANT INFO��NIATION; Name: Jc.i�aare.�r "�v�oS Y,_._ __. State License# �,o��„�.3 G, � ��' _�.,, Expiration Date: 3 J � ,�.. Phone: ��—,� 7>— /�D O office � (cell) Mailing Address: �7SL � �e, � (� Ci �v1 S ZIP: �S 3�/ Contact Person: '}3�}� ��v.:c k: Applicant is: ontra o / Homeowner �circioa,.� Email and/or Fax: �S�-—a 7�— I�td _.,_, PROPERTY OWNER INFORMATION: Name: C.�r'�S �- ��`�-1�9..r �c�� _.. _ Phone(day): 9,Sa-- - !ac)o� Address: ,.. �o�v o c�r..� � Cp ----M CitY:�ro r�c� • ZIP: 3�5,3.�� Email and/or Fax PROJECT INFORMATION: 7ype of ProJec� �� Any earlh movement may require MCWD revlew S permits ❑Door(s) ❑Remodel ❑Water Damage Minnehaha Creek Watershed Distric�(MCWD) (�Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka BNd Deephaven, MN 55391 ❑Siding ❑Resiordti0n ❑Other.(speclfy) Phone: 952-471-0590 FdX; 852�t71-0682 ❑Re-roof ❑Fire Damage www.minnehahacreek.om Overall Project Descri�tion: � �.h o1 c.��►. 'ows 1►�. ��i s�:v�s o�e.►�'��nS S Estimated Constructlon Valuatlon of Proje �excludin�land) � S/ 6 S APPLICANT ACKNOWLEDGEMEMT; . Agrees to provide all infortnation required or requested by the Building Department; . Certifies that the information supplied is true and corred to the best of his/her knowledge. The applicarrt recognizes that they are solely respansible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or alf of the information that you are asked lo provide on this application is Gassified by State law as either private or confidential. Private daca is information which generally cannot be given W the public but can be givan Io the subject of the data, Gonfidential data is information which generally cannot be given to either the public or ihe subjeet of the data, Our purpose and intended use of this information is to annually update our reca�ds and fecords of other govemmental agenaes re uired b law. If you�h,se to supply the inFormation,the applippon ma not be issued. . . X:, Applicant's Si9nature: 1�� _ R Date: 7 '� 7"� � , Last Updated: 05-042009 �