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Sep, 10, 2009 4: 23PM No, 3503 P, 2 � + Cifiy of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) MailingAddress: Permit number . "� �'u -C;��✓�"� Og,O j� PO Box 66 � Crystal Bay, MN 55323-0066 Date�ec�ived: � o, Strset Address: Received by: �., C �, � G� 2750 Kelley Parkway Plan re,►iew fee: (�� '�h.��og� Orono,MN 55356 �,2 � � 7otal Fee: �,n�� , � \ Main, 852-249�600 Fax: 952-249-4616 www.ci.orono.mn.us ` ` p This application form must be completed in full and all required information must be submitted. , �(0� Incomplete epplications will be returned. (Please print) �-G GENERAL INFORMATION: d 1� _ �� Job Site Address: ��( Sky�afwl,b J('�1lQ Will this be a Parade of Homes, Remodele�s Showcase Home or other Display Home? ❑ Yes � No !f yes,a special event permit Is required with Pollce Department and City Councll approval 60 days prio�lo the event. Shunle bus service will De requlied unless applicant demonstrates sulflGent on-slte paiking(s ava!!able. Non-permltted events will nat be allowed, CONTRACTOR/APPLICANT INFO ATION: Name: .,S"cher�e,� � C� • State License# 9 Expiration Date: �' ! l Phone� '1- p office cell Mailing Address: ,�'� ` Y Ci . in S ZIP: 3 3 Contact Person: Applicant is: Contractor / Home�wne� tc►�e o�e) Email and/or Fax: x ��—1�Qo PROPERTY OWNER I�RNIA��N�� Name: Od�d Phone(day): - - 7 Address: �061 �aarwr�d riVc Ciry: ��'DrlO ZIP� ,S.Sj�o Email andlor Fax PROJECT INFORMATION: Type af ProJ�ct: Any eerth movement mey require MCWp review 8�permits ❑poo�(s) ❑ Remodel ❑Water Damage Minnehaha Greek watershed�istrict(MCWD) �findow(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55381 ❑Siding ❑Restoration ❑Other:(specify) Phone: 952-471-0590 Fax: 952�71-D682 ❑Re-roof ❑Fire Damage www.minnehahacreek.om Ove�all ProJect D�scMptlon:� 1 r a C2r►�,�� bne W ' 0 u ��n�o �Q n � Estimated Constructlon Valuatlon o ProJect(excluding land) $ 1�� 1-j3(o APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Buifding Department; • Certifies that the information supplied is true and corred to the best of his/her knowledge, The applicant recognizes that they are solely responsible for submitting a compfete application being eWare thet upon failure to do so,the staff has no altemative but to reject it until it is complete; • Soma or all of the information that you are asked to p�ovide on this application is Gassified by State law as either private or confldential. 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 tha public or the subject of the data. Our purpose and intended use of this information is to annually update our �cords and records of other govemmental agencies re uired b law. If ou refuse to su I inform 'on, the a lication ma not be issued. Applicant's Signature: � Date: _ �/��09 Last Updated� D5-04-2D08