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APR-1-2011 04:23 FROM:TREBILFOUNDATION SYS 3205938720 T0: 19522494616 P.2/3 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> -�„ Malting Address: Permit number: 07D��--- .00/97 <br /> .�� PO Box 66 <br /> Q 0 Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: 11�S <br /> ~ Kelley 2750 <br /> Ey Y Parkwa Y Plan review fee! <br /> Orono, MN 55356 Total.Fee: <br /> Mein: 952-249-4600 Fax, 952-249-4616 www ci.Qr4n4 mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INORMATION: Incomplete applications will be returned. (Please print) <br /> F <br /> Job Site Addr ss: r S 3S <br /> Will this be a P irade of Homes, Remodelers Showcase Home or other Display Home? Ll Yes KNo <br /> If yes,a Special vent permit is required with Police Deparrment and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> req red unless applicant demonstrates sufficient on-site panting is available. Non-permitted events will nol be allowed. <br /> CONTRACTOR APPLICANT INFORMATION: <br /> Name '�� � `; \ r�A. �.. g­�s�c <br /> State License# spy 4��g� Expiration Date. <br /> Phone: Lon (office) (cell) <br /> MeilingAddress: ; ZIP:Contact Person: Lr Applicant is: ntra J Homeowner (Circho Ono) <br /> Email and/or Fa : 7V3Z Q <br /> PROPERTY 0 NE INFORMATION: <br /> Name: h,r,� " <br /> Phone (day)' <br /> Address: '�q�—t- yCity' ZIP: SS351„ <br /> Email and/or Fax 'r — <br /> C.O <br /> PROJECT INFORMATION: <br /> Typo of Projact; Any earth movement may require <br /> ❑ <br /> MCWD review& permits Remodel Water Damage <br /> ❑Window(s) Repair Minnehahs Creek Watershed District(MCWD) <br /> Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration Other. (speciry) Phone: 952-471-0590 <br /> ❑Re-roof ❑Fire Damage �-���� Fax: 952-471-0662 <br /> www minnehahacreek ora <br /> Overall Project Description�n� �� 1a 0.nC+�LteS <br /> Estimated Construction Valuation of Project(excluding land) $ `ZLkO CM <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 submltting 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 /> • Some or all of tho 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 eubject 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 is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information the application may not be issued. <br /> Applicant's Signature: <br /> � �� l n Q � � Ci-cQ^+� Date: <br /> Last Updated, 05-04-2009 <br />