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�09AL'2010 11:39 7634344933 HARMONY HOMES INC PAGE 02 City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) --� Mailing Address: PO Box 66 Permit number; - lO Crystal Bay, MN 55323-0066 Date received: a Street Address: Received by: o+ 2750 Kelley Parkway Plan review fee: Orono,MN 55356 Main: 952-249-4600 Fax; 952-2494618 www.d.orono.mn.us Total Fee: This application form must be completed in full and all required information must be submitted,7` Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: /3210 I !W� /✓✓r £ 3�p Will this be a Parade of Homes, Remodelers Showcase Home or other Display Homed Yes o K yoa,a spacial event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site partdng is avallable. Non-permitted events will not be allowed. CONTRACTOR/ PLICANT INFOM%Mr->S ATION: Name: %AE0kQNyI IJ State License# I 2D15 o l -5 Expiration DW-e: 5, 31 / z Phone: ?--4 V�057-7- office cell Mailing Address: I%Zo I QT-NL 9� F Ci!y: S ZIP: 5'S t 3 Contact Person: �ww� u�e_�� Email and/or Fax: v RSA Applicant is: ontra / Homeowner (Circle One) RY►10 N �h F 5 10.1 G.1J�� PROPERTY OW R INFORMATI Name: IL G ¢i, Phone(day): c 13 Y Address: k-Go Ci %) ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require K ) MCWD review& ermits ❑ Doo s El El Damage p Windows) ❑ Repair Minnehaha Creek Watershed District(MCWD) ❑Storm Damage 18202 Minnetonka Blvd [I Siding ❑ Restoration Deephaven, MN 55391 ❑Other, (specify) Phone: 952-471-0590 ❑Re-roofFax: 952-471-0682 ❑Fire Damage www.minnehah ek_orn Overall Project Description: UJ t\o 1,,,, ., Xt t p -r-=01 N fO Estimated Construction Valuation of Pro'ect excluding land) $ (o to 3 Z APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject It until it is complete; • Some or all of the Information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is Information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to an ally update our records and records of other governmental agenoles required kX law. If you refuse to sunoI the informiltio e acolication may not be Issued. Applicant's Signature: Date: J Laat Updated; 05.04-2009