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2�10�-�3 05:05 GRUSSING 9529356514 » +9522494616 P 2/3 <br /> � City of Orono <br /> � Building Pe�mit Application for Internal Work <br /> windows, doors, siding, re-roof, etc_) <br /> -_7 --- Mailir�g Addrsss; Permit number: - Q 9b <br /> �'¢r�.�Q� PO Box 66 <br /> 1 Cryatal Bay, MN 55323-0066 Date received: /(7 <br /> � . �„l S(/eet Addros�.c: ReCeived by: . <br /> �% 2750 Keliey Parkway Pla��eview fee: <br /> '� ��,,� Orono,MN 55356 � <br /> - -� Totel Fee: !� / �5D <br /> Main: 952-249-4600 Fax: g52-249-4616 www.ci.orono.mn.us �6P-� <br /> This applicstion form must be completed in full and all requir�d informatian must be submltted. <br /> ! leoomplete applications wlll be retumed. (Please print) <br /> GENERAL INFORMATION• <br /> Job Sit�Address: � �0�J /y�' .�, <br /> Will this be a Parade of Homes, Rem dels Showcase Home or other Di�play Home? Yes o <br /> /fyes,a special svent pBrinJl 15/Eqf1/Ie�Wilh PpliCe DepeRmellt 2nd C/ry COunCil epprov8160 days prior fo the ewint. Shuttle bus sen•ice wi/I 60 <br /> , required unlass epplicant de►nonsMalea sufl'�cient on-site parking is eveilebla, Non permttted events wi/I nor be allowed. <br /> CONTRA`CTOR/qPPLICANT INFORMATION: <br /> Name: : S/h� � ..YI�1C. <br /> State License# Expi�ation Date: 3 31 1 � <br /> Phone; .� C 55 ? oifiee) ,,�.-3(m - �! y (cell) <br /> Mailing Address: � Ci : ZIP: <br /> Corttact Perspn: Applicant i�; C / Homeowner (Cllclo Ona) <br /> �mail and/or Fax: �,r � ri,t tsi/rJ /�v •r vj ��� <br /> PROPERT�'OWNER INFORMATION: <br /> Name: � �o�.w►hs-{gy� <br /> PhonB(Cay); � L/ _ �./fl <br /> Address: : , .S Sr��-�n� l�-Lf i2,�. c�ty: 0o-�r,rZ_ _ zIP, 5.��9 <br /> Email and/or Fax <br /> PROJECT INF�RMATION: <br /> Type oi P ject: Any Qarth movatner�t may reqwrc <br /> ❑boor(�) ❑Romodel MCWD r4vigW g Pe�;�� <br /> I ❑Water DamaSle <br /> � Minnehaha Creek Wstershed aistrict(MCWD) <br /> Q vVlndovJ�(s) ❑RQpair ❑Storm Dsmage 18202 Minnetonka BIvC <br /> Dee aven.MN 55391 <br /> ❑S' ing � ❑ Restaration ❑Othe�: (speGi� Pha��iw: 95a-471-0590 <br /> � FaY: 85Z-471-0682 <br /> Re-roof� ❑ Fire Damage www.mir�pg� .or <br /> Ov¢rall P�'oject Descriptlon: . 0 ' �,�r l��C'—VdD-� P!7��f' tiyv�.. . <br /> Estimated Construction valuation of ProJect(excluding land) S �o�lo� � v�•S' <br /> APPLICA;NT ACKNOWLEDGEMENT: <br /> • AgPees to provide all information required or requested by the 8uildinp Deparlment: <br /> - Cekrtes that the information supplied is Nuc end corr�ect to the best of his/her knowledge. The appllCant recognlZes thet they <br /> ar�solely responsible for�ubmiffing a complpte applicstion beiny awurc that upon f8iluro to do so, the statt has no altemative <br /> bu to rejeG i[until it iS COmplete; <br /> • 3o e or all of the IntOrm2tfon that yoU are asked to provide on this applicat4on is dassified by State law as �ither pnvate o� <br /> co �dcntiel. Pr�vate data is information which generar�y cannat be given to the public but can be given to the subject of the <br /> d . Confidential deta is information which generdlly callnot b6 glven to either the public or the subject of the data. Ou� <br /> pu ose and int4nded use of this infom,stior� io to onnually update our recorqs antl reoorcls of other goyemmental agencies <br /> reauired by law. If au rafuse fo su I the ir�formatlon,the app�jcetion m�y flot bc i9aued. <br /> I _ <br /> I <br /> Applicant's;Signature: Date: ) � (3�� _ <br /> . , <br /> Laat UpAatetl:�05-0�2D09 <br />