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City of Orono <br /> i - Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> 0 i MMailing ddr66 Permit number: p3/D—�OD <br /> Crystal Bay, MN 55323-0066 Date received: - Id0/47 <br /> A � � e y,l/� Street Address: Received by. <br /> ti 2750 KelleyParkway ` \- <br /> \`lkEss e/ Orono, MN55356 a\_, GNU,:ft.,_ <br /> _ Plan review fee: o� �,Sl �� <br /> �� � ,4-\\-)-\\(\l/\V711 O7h/Of 0©vp7 <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: c360 G!)/4c(?4T14 &vt <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? (l Yes g 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: 60R tstwo .seinte S 604.,5TgLAC75owL, <br /> State License# 4:20.5-319 (o/ Ex•iration Date: <br /> Phone: - office /, -9-373 Co (cell) <br /> Mailing Address: O BOX 3041 c-Lc ala.%. S# - 0.2oo Cit - E Pow,aZIP: 55'3,c9 <br /> Contact Person: SOg Mc P HERS o"./ Applicant is: Conctortra / Homeowner (Circle One) <br /> Email and/or Fax: joe a@ orolor -Jwt <br /> ge-5 • corn <br /> PROPERTY OWNER INFORM TION: <br /> Name: // /EST moo ) Co-of <br /> Phone (day): 4424/6 <br /> Address: 4.?31C0 cJPitVmr.4 &vb. City: pRAevO ZIP: S5-3..c4 <br /> Email and/or Fax ,ypy,E <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth 7-••----`--_.. ___._.__ <br /> MCWI <br /> ❑ Door(s) ,emodel E Water Damage _ <br /> Minnehaha Cree <br /> ❑Window(s) El Repair El Storm Damage 1820 -----1 1 <br /> ❑ Siding ❑ Restoration D ,..(10. d-r it\4'tj\. . <br /> �/° <br /> ❑ Other: (specify) Phot <br /> ❑ Re roof Fa; / t \V <br /> ❑ Fire Damage www.r /. --;: 77! <br /> .4,/') <br /> c� ti <br /> Overall Project Description: 7�' �0?PI20UEN74'01 <br /> Estimated Construction Valuation of Project(excluding land) $ 4f501 000 <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: 71_,21 Date: a—/S Oji <br /> Last Updated: 05-04-2009 <br />