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Jun 29 09 06:35a Straub Design 952-546-3056 p.1 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc) <br /> Mailing Address: <br /> 0 Permit number: (� - <br /> ¢, PO Box 66 <br /> 0 0� Crystal Bay,MN 55323-OD66 Date received: lv b <br /> ++ "''�"'' <br /> 4� Street Address: Received by:i <br /> 2750 Kelley Parkway Plan review fee: <br /> Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 vn,vw ci.orono.mn.us Total Fee: <br /> This application form musi;be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 1.? y /O <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes X No <br /> ff yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttie bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Nor-permitted events will not be allowed. <br /> CONTRACTOR /APPLICANT INFORMATION: <br /> Name: 401440(_ Omex5/ <br /> State License# Expiration Date: <br /> Phone: (office) _ (0/Z--3j0— SZcr�/ (cell) <br /> Mailing Address: ,AQ <br /> CRY: ZI 9 <br /> Contact Person: 4¢,G"4 Applicant is: Contractor / Homeo (circia one) <br /> Email and/or Fax: ? tIZe <br /> PROPERTY OWNER INFORMATION: r <br /> Name: <br /> Phone(day): r <br /> Address: —4 IWO_7 SPD City: AZO_13�_ ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8 permits <br /> 19 Door(s) Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> [ Window(s) C] Repair (]Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Re-roof ❑Fire Damage ..ww.minnehahacreek.orq <br /> Overall Project Description: pL <br /> F.�'1« lO-t► _ 124cMove. $C/`sQNs fttv5r►w�1 i1.Iw,Anwf <br /> Estimated Construction Valuation of Project(excluding land) $ ?� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge_ The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete, <br /> i <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information i to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the in mation.the application may not be issued. <br /> Applicant's Signa e: Date: 09 9 <br /> Last Updated: 05-04-2009 <br /> I^ " .e Cv-L.9 -0 y �. C.�_ ���� ,.v S t i=r.v A c-.. <br />