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City of Orono
<br /> Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: Permit number:
<br /> Og, 0 CrysPO tal
<br /> 66
<br /> Cstal Bay, MN 55323-0066 Date received:
<br /> .r by:
<br /> A cII _^" ;., s, Street Address: Received
<br /> ��, )(Al Gtiti 2750 Kelley Parkway Plan review fee:
<br /> `�kEsso4`4,0
<br /> " Orono, MN 55356
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<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: 2/545b(r)a....&11-71V1.(—)i'7 '( 4;,,,,,,,:.,
<br /> Will this be a Parade of Homes, Remoders Showcase Home or other Diay Home? ❑ Yes j2No
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: -71,vt.b.c4.4c.et,-Q, QY[GY'j Me •
<br /> State License# Lo 33W''7 Expiration Date: 3 . i 1• _
<br /> Lead Certification Number: /1/4441— y y37c - ( Expiration Date: 5 - g-46 -
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (office) 4%5/` 3 - gFre/a. (cell)
<br /> Mailing Address: 7tv(, F' F,5h Ll_ rd City: (i 6,,,ev,c ZIP: 5531
<br /> Contact Person: (,.15/ . 9-6,,91 e,;, Applicant is: Contra or'-) Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name:
<br /> 52.,04_ eYe)L-L
<br /> Phone (day): �
<br /> Address: •ri/54/5 In xtCY 1.U,-1 Thi City: 7--)
<br /> (....,,i--6 ZIP: 5$ '
<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 grStorm Damage 18202 Minnetonka Blvd
<br /> ❑ Siding /Restoration ❑ Other: (sp cify) Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> /rRe-roof ❑ Fire Damage Fax: 952-471-0682
<br /> www.minnehahacreek.org
<br /> Overall Project Description: 7, y ee,�
<br /> Estimated Construction Valuation of Project(e ding land) $ i5; 6 d 6
<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 pannot 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 th infor ation,t application may not be issued.
<br /> / . ,
<br /> Applicant's Signature: C/ Od ,(,� Date: /( - ( 6//
<br /> Last Updated: 03-01-2011
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