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Jun 1311.,12:29p Hubbs Construction 651-653-3234 R,2 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> -- <br /> �r0 Mailing Address: <br /> . , �; PO Box 66 Permit number. o?D 1 Qy�S <br /> 10 Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by. <br /> 2750 Kelley Parkway <br /> Orono, MN 55356 Plan review fee: <br /> Total Fee: I D, 0 U <br /> Main: 952-24911600 Fax: 952-249-4616 ro <br /> ci.on .mn us I <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: 3-5 ToNka - w L-m n <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes VXNG <br /> H yes,a special event permit is required with Police Department and City Council approval 80 days prior to the event Shuttle bus se ice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non permitted events wdl not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: - <br /> CO Y� • G <br /> (/� <br /> State License# a Cl)a 1 Expiration Date: a <br /> Lead Certification Number: W PCT_ �� �� _ Expiration Date: a aL4 I <br /> {for work on homes thatwere constructed prior to 1978 <br /> Phone: - -t_ (office) j CkvA Co (a- - aFa (cell) <br /> Mailing Address: JE�tjwavalvd <br /> N CRY; ZIP <br /> Contact Person: ) • Applicant is: o rao / Homeowner (circle one) <br /> Email and/o j Fa3ax (,,5' 1 — Ll.-Z(0 —i]31 1 _ <br /> PROPERTY OWNER INFORMATION: <br /> Name: i til rk- <br /> Phone(day): _8is - -7 - <br /> Address: c c C-pnp ZIP: - <br /> Email and/or Fax - <br /> PROJECT INFORMATION: <br /> Type of Project: WeAny earth movement may require <br /> i h� <br /> [IDoor(s) ❑Remodel Nater Damage 1& MCWD review&permits: <br /> ❑Window(s) ❑Repair Minnehaha Creek Watershed District(MCWD) <br /> p ❑Storm Damage S. 18202 Minnetonka Blvd <br /> ❑ <br /> Siding ❑Restoration ❑Other. (specify) Deephaven, MN 55391 <br /> ❑ Phone: 952471-0590 <br /> Re-roof <br /> ❑Fire Damage Fax: 952-471-0682 <br /> loww.minnehahacreek.orall <br /> Overall Project Description: e f a c rti•'t <br /> Estimated Construction Valuation of Project excluding land) $ C1f Cc: <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 /> 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 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: J Date: tp 10 <br /> 1-J I I-J-L-J, M M MAA <br />