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2010-07-06 06:04 GRUSSING 9529356514 » +9522494616 P 2/3 <br /> R <br /> . ~ City of, Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> ,,.:-"�•-. M�iling ACdress: Pemlit number <br /> O�,O,�O PO Box 66 . . <br /> Crystal Bay, MN 55323-0068 Dete r'eceived; <br /> a ' �,� Sfreet Address: Received by; <br /> � ��' 2750 Kellsy Parkw�y Plan revleW fee: <br /> ���'� Orono, MN 55356 • <br /> — Total Fee: <br /> Main: 952-249-4600 Fax� 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all�requir�d information must be submitted. � <br /> Incomplete applications wlll be retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � , ` /� ' ��. <br /> wll this be a Parade of Homes, Rem ele howcase Home o�other Display Home? Yes No <br /> N yaa,a special event pt►rrlt/s requin�Id with Polke D�pertment end C�1ry Council approva/Bo daya prior to the su�snl. Shuttle bus sanNce wfA be <br /> requlled unless applican�demonstrstes sufficlent on site perkinq is evailable. Nor►-p�►mr7}ed events w/l!not be a/bw�ed. <br /> CONTRACTOR/APpLICANT INFOR ATJON: <br /> Name: �M 5 y��f vT7¢r vf �►r,C <br /> State License# (, y Expiration pate; <br /> Phone: S -93 '- S S office a-�J -07� cell <br /> MailingAddress: Ci ; y zIP: �'53+�� <br /> Contact Person: Applicant is� ontra or Homeowner �ci���on.� <br /> Email and/or Fax: �- _ 3 p <br /> PROPERTY OWNER INFORMATION: <br /> Name: �� �� <br /> Phone(day): �5�� 4-►3-���� <br /> Address: '7(v�' �,�,•.L 1.�,�� City:Ol/��3'LO ZIP: �j5�� <br /> Email and/o�Fax i��l � `�'� � <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may requlre <br /> MCWD review$permlts <br /> �]Door(sj ❑Remodel ❑Water Damage <br /> ❑Window{s} ❑Repair I Minnehaha Creek Watershed Distnct(AACWD) <br /> I ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Sidin9 ❑Restonation Deephaven, MN 55391 <br /> ❑Other: (specify) Phone: 952-471-0590 <br /> FaX: 962-471-0682 <br /> �roof ❑Fire DaRlaqe � _, www.minnehah�creek.org <br /> Overall Pro'ect Descrlption: ' � <br /> Estimated Constnaction Valuation of Projact(excluding land)��j�y, � <br /> APPLICANT qCKNOWLEDGEMENT; <br /> • Agrees to provide all information requi�ed or requestecl by the Building DepE►rtrnent; � <br /> • Certifies thet the informatio�supplied is Uue and coirec[to the best of his/her knowledge. The app(icant recognizes thet they <br /> are solely responsible for submitting a complete applicetion being aware that upon failure to do so, the staff has no altemabve <br /> but to feject it until li is complete; <br /> . Some or all of the information tt�at you are askad to provide On this appllCation is Gasslfled by 5t2te laW e5 eithe�prlvete or <br /> confidential. Private data is informadon which generally cannot be given ro the publi� but can be glVerl to the SubjeCt of thq <br /> data. Confidential data is infonnation which generally can,riot be given lo either the public o�Ule subjeCt of th@ dat'a. OUI' <br /> purpose and intended use of this infiormation is to annually update our r�cords and records of other govemmeMal egencies <br /> , required bY 18w. If you refuse to SUpply the information,the application may not be issued. <br /> ApplicanYs Signature: <br /> ���'�. Oate: �7 l0 1 U - <br /> Last Updated: 05-042009 <br />