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�hov 22 10 04: 41p mike schrader 763-444-1199 p. l <br /> ow <br /> City of Orono <br /> 8uilding Permit Applicatron for tn#ernaf Work <br /> � (windows, d�Qrs, siding, re-roof, etc.) <br /> Mailing Address:.. . <br /> 0 PO 8ox B6 Pemnif number: . , � <br /> � � 1 _ <br /> . O . 0 - Crystal.Bay;MN.55323-OQ86. Date resetvpd: �/. � <br /> SYraetAddness: Received by: . <br /> � �� 2750 Kelley Parkway <br /> � �, ' Flan review fee: <br /> ��o� Orono�MN.55356� " <br /> Main: .952�249-4600'.. Fax: 952-249-4616. Total Fee: �]8/ <br /> www.ci:orano.mn.us ' / .ri. <br /> This appiication form must be completed:in,full and ail required information must be submitted � <br /> incompfete applicatians wili be.retumed. .(Please print) � <br /> GENERAL'INFORMATfON: � <br /> Job 3ite Address:� .n , . - <br /> �Il�this be a Parade of Homes, Remodelers howcase Home other Display Home? Ye ❑ No <br /> !f yss,a speclel event permit is requiied with Pofiae Department and Cify Counctl p prova/60 d a y s p r l br t o t he event S huCle bus rvice wr11 be <br /> requlred un/ess applicant demonsbates su�clent cn-site;paricfng ls.a a//ab/e. Non�ermitfed events w!!1 nof be a!lowe <br /> CQNTRACT�R/APPLICANT INFORMATION: <br /> Name: ( � a� , <br /> $�ate �icense# ' ��s-z�PsP�i� Expiration Date: ' ,� <br /> Phone: . office cell <br /> Maiting Adtlress: C' : ZiP: <br /> Contact Person: c .r I ApPiicant is: Homeowner <br /> Email and/or Fax: �, � (circie one� <br /> ' e <br /> PROPERTY O.WNER iNFORMATION: � <br /> Name: Q . <br /> Phone(day): a. . . <br /> Address:. C' : ZIP: <br /> Emaii artd/or Fax <br /> PROJECT INFORMATION: <br /> TXpe of Project: Any earth movemerrt may qulre <br /> [�Door(s) ❑ Re.mode! MCWD revi�v 8 perm � <br /> C]Water Damage . . <br /> ❑Wndow(s) ❑ Re alr Minnehaha Creek Watershed Di ct(MC1ND) <br /> p ❑Storm.Damage 'l8202`Minrtetonka Blv <br /> �Sidin9 ❑Restoration �Other: s eci Deephaven;:MN 5539 <br /> ( P �) Phone; 952-471-059 <br /> ' Re-roof Fax: 952�71-0682. <br /> ❑�ire Damage .mi eh ha ek <br /> verall Project Description: <br /> Estilnated.Construction Valuation of Project(e cluding land) $ � <br /> �APPLlCANT ACKNOWLEDGEMENT: �cJ/�, SG//h <br /> • Agrees to provide.:ail ir�formetion required or requested by the Building Department; <br /> �7�fi .�t �� <br /> • Certifies.that the infQRnation supplied is true and correct.to the best of his/her knowledge. The.app ipnt nJzes that they , <br /> ° are.solely re�ponsibie for submittfng e complete application being aware that upon failure to do so�, fhe staff h no altematiwe <br /> but to reject it ur�tfl it is complete; <br /> � . 5.o.me.or ail.aF the information that you are asked to provide on this appiicatio�is�a�,ssifie b State �av�a$ f�e`r rv tr�or <br /> confideMial. .Private dafa is (nformation which °1 P <br /> generally cannot be given to the public but,can be given to th subject of the. <br /> data. Confidential .data Is inforrnation w ich.generally nnot be given to'elther the public ar the subject the data, .Our <br /> pyrpose and inten.ded use of this.infor at3on.is fo.an Ily update our records and records of othe�:gevem ental agencies <br /> r.e ulced b law.'If ou refuse to I the in io e a lication ma not be issued. <br /> Applicant's Signature: Date: l��j .`D <br />