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V" <br /> l X957 <br /> City of Orono �� 1 <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: ap /_C7Q <br /> 0 PO Box 66 Permit number: <br /> 1 Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: 11_� L U <br /> 2750 Kelley Parkway Plan review fee: 5�P�• 1 <br /> �t`9kESH��� Orono, MN 55356 <br /> _— Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ' 771 <br /> This application form must 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: IQ p <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus serve a will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INF MATION: <br /> Name: K-E t"14 ASSQClP�'T£S, WC. <br /> State License# f 5o8 Expiration Date: -31!S 1 126 L-2- <br /> Lead <br /> zLead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: q52--1741- OOO (office) (cell) <br /> Mailing Address: Z„ p City: ft.X! IP: 5 <br /> Contact Person: SkQP�14 Tt.LaLE(2 Applicantis: on ractor ! Homeowner (CircieOne) <br /> Email and/or Fax: y5&Rp ,4p @ k.E1TMUJA7EIZS relsq ! FAX ; 16 Z• 4174' dodq <br /> PROPERTY OWNER INFORMATION: <br /> Name: I�GNWI� Cc � <br /> 4N-%ttP2 . <br /> Pllik . <br /> Phone (day): (AZ - 881• (e'l I <br /> Address: 10 30 Td rJ kA W A 7-0oiND City: d"p ZIP: c), 3��{ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> Overall Project Description: = W , <br /> Estimated Construction Valuation of Project(excluding land) $ 71 q. 000 A0 b 44+r14 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> VE 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: Date: <br /> Last Updated: 03-01-2011 <br />