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$ /// 7Y17S <br /> i‘j,,,,,'C- \\1 City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: pY)/.0"b OO <br /> PO Box 66 <br /> O¢ �� Crystal Bay, MN 55323-0066 Date received: 7/aD lO <br /> Received by: <br /> � ,� 14:te'H'-, �,;, Street Address: pct <br /> ''''`'-4.,,,;,t6," ��% 2750 Kelley Parkway <br /> •1._. ...,r,-),.\'� Plan review fee: �03 &l O ,/ <br /> 8o4 � Orono, MN 55356 .i� � �'� ry,v, p j/�.0 e 7 <br /> \,',,\1'" Total Fee: d <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: c2350 Let ti?4T14 BLIT b <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes e.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 service ill 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: (OR[ v •1401e S O0ivsretAc'T.Tt—J <br /> State License# 070S 3 19 lc I Ex.iration Date: <br /> Phone: - office i. -q-373 C. cell <br /> Mailing Address: p ;_•_ ,c/ . c Mar" # - *1.2O0 Cit : - e Rosa/ZIP: s - <br /> Contact Person: �Og Mc?HERS onl Applicant is: Contractor / Homeowner (circle One) <br /> Email and/or Fax: Joe l`.`: ,,,.,,,..ti„„o10 -Jtn <br /> awie5 • ur <br /> PROPERTY OWNER INFORM TION: <br /> Name: //4RVEST mom) a-o? <br /> Phone (day): AWE <br /> Address: o'3d 0 WPHI?i4Tr4 &vb. City: Q, pwo ZIP: $53SCo <br /> Email and/or Fax ,f(Myt <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.org <br /> Overall Project Description: 'tel , .•tPteovew/Ew- <br /> Estimated Construction Valuation of Project(excluding land) $ 4'SO,ta00 — <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 suppl the information,the application may not be issued. <br /> Applicant's Signature: 7r9 --- ---- Date: 1-45.--/i0 <br /> Last Updated: 05-04-2009 <br />