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JULs18-2@+11 11:21 From: 6785736615 To:9522494616 Pase:1�1 <br /> '' ►/n. <br /> vv/ <br /> , `�` �� <br /> C�ty of Orono �� �� � <br /> Bujlding Permlt Application for Internal Wo�k f�� . <br /> windows� doors� siding, re-roof, etc. <br /> Ma�7ing Addrreess: Pem�it numbsr. ��3 - 0 7 <br /> O���O PO Qox 66 <br /> Crysigl Bsy,MN 55323-0068 Oale reoeiv�d: 7 ! 6 <br /> � � Street Address: ReceNrad by: <br /> 2750 Kerlty P�rkwaY Plan review ise: <br /> �► �ono,MN 55356 <br /> Total Fee: � �`�,�� <br /> Main: 952-249-4600 Fax: 952-249-d�i16 www.ci orono mn.us <br /> Tttis application form must be completed in full and all�equired inform�tion must be submiaed. <br /> tncomplete appllcations w111 be retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �i� �.S �-yl• <br /> Will this be a Parade of Homes,Remodelers Showcase Homo or other Display Nome? Yes No <br /> Il pes,a special event pemJtls ieqtdied w�fh Polke Departn�ent and t�'ry COwtt�1 sp�rovel 60 days prfor b fhe ev�nL Sh�Cle bt�s seivk:e wd'I be <br /> requNed unless appRce�dema►sarates sullFaent ons�pa,kb►q is eveilabis. Nan-pem►�ted erenla w�not 6e aQow�ed. <br /> CONTRACTOR/APPLICANT INFQRMATION: <br /> Name: ' <br /> Stste l.ioense# �;Q�3 b5 h Expiratlon Oate: p3 � <br /> Lesd CeKiflcat�on Number. Expira�on Date: <br /> (1bi w�odc on homes Mat were consbucted prlor b 1978 <br /> Phone: �I Z- BF���Dc O (office) (cell) <br /> Ma���ng�eress: t2366 12�v� 12.tctc�c. Si�roL. �hr C'a-�o ZIP: 1�w1 <br /> Confact Person: � s; Applicant ts: Contractor I Homeowner �c�ra.0�1 <br /> Email andlcr Fax: �h��S�,�,�,o,���hS � ,,�,y"� <br /> PROPERTY OWNER INFORMATION: 1 <br /> Name: �t �- �. C � �1,J�o�'�1, , <br /> Phone(daY)- '�52 ��- Of�O <br /> Address: ayS G���p� L-y�- City: O ra� ZIP: �3�(,� <br /> Email and/er Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: y es�tlf moverr�nt may require <br /> ❑Door(s) ❑Remodel ❑Wster Dsmage MCWD revlew 8 permlts: <br /> Minnehaha Creek Watershed DisMct(MCWD) <br /> ❑Window(s) (j�epsi► ('�8tortn Damage 18202 Mrnnstonka Blvd <br /> Deephaven,MN 55391 <br /> ❑Siding ❑RestorsHon ❑OtAer.(speciy) Phone: 952-471-05�0 <br /> �e-roof ❑Fire pamage Fs�c 952-471-0682 <br /> www.minnehahacreek.om <br /> Overall Pro act Desc�i tlon: �-so � �„„� C r,.�, <br /> Estimated Con�huCtion Valuatlon oi Pro ect excluding land) 3 2.'3 (, Qy� � - <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Aprees tv prwide all iMormabon nequired or requested by the Buflding Departrnent; <br /> • Cer'tr�ies thal Iha informaUon supplied is true and correc!bo the besl of hldhe�knowledge. TAe applicant�eCognizes that they <br /> are soley responsible for su0mitting a mmplete applicapon being eware that upon/ailure to do so,the staff has�o altemative <br /> bul t0 rejed il uMil it is oomplcte; <br /> • Some or all oi IAe informalian thal you are asked�o provSde on this applicadon is classifieed by State law as eitl�er privabe or <br /> oo�identlal. Privdte dab is infortnetion whid�generally cannot be given to 1Ae publk�ul csn be given b the subjed oi Ihe <br /> dala. Confidenl�al dale is iniom�adon which generally cennot be given to eiMer tl�e public cr Iho eubjed of the data. Our <br /> puryose snd inbended use of fhis inionneUon is 0�annualy update our records and records of olhet govemmenisl apencies <br /> ui b law. Ii reiuse to su the irtto ti� the a ication ma not De issued. <br /> Applicant's Signature: Oate: 0�1�1�� �` <br /> Lsst Undated: 03-01-2011 <br />