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JUN-30-2011' 13: 18 From: To: 19522494616 Pa9e:2,2 City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) .�O� MaibPO Boxr66 Permit number. O 0 Crystal Bay,MN 55323-0066 Dale received: / Street Address: Received by 2750 Kelley Parkway Plan rev' ee: �' Orono,MN 55356 To I Fee.. �, Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono,TD u This application form must be completed in full and all required information mus . Incomplete applications will be returned. (Please print) GENERAL INFORMATION: �� Job Site Address: Will this be a Parade of homes, Remode ers Shawcase Home or other Display Home? Yes b4 No N yes',a special event permit is required with Police Department and Cit'Council approval 80 days prior to the event. Shuttle buss ice wX Do required unless applicant demonstrates sufclent on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: 17IA49AI State License# [ 7,3 P Expiration Date: Lead Certificatlon Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: Itp 4 . �/• 71M (office) (cell) Mailing Address: City. yw ZIP: Contact Person: �L/G � Applicant is: ntract / Homeowner lcimia one) Email and/or Fax: �� iyy, yli�h, e4ol-I PROPERTY OWNER INFORMATION: Name: 19-1V11t�if� Phone(day): -&41- 240• 62a Address: JX-,5 ' �j -,-y/ City. 14U/L/7) ZIP: � Oe Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(s) ❑Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑Repair Q Storm Damage 18202 Minnetonka Blvd Siding ❑Restoration ❑Other. (specify) Deephaven, MN 55391 Phone: 952-471-0590 Re-roof 0 Fire Damage Fax: 952-471-0682 www.minnehahacreek.cm Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ 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 th 'nformatio is to annually update our records and records of other governmental agencies required by law. It you refuse 6 suP6, th nformay9n,ffiR application may not be Issued. � Applicant's Signature: �,21Date: