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�� Ica <br /> UtJ X110 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc) <br /> 0 $6-:-) <br /> Melling BoxBB: Permit number: c:26 d -O(7 V 5�2� <br /> Crystal Bay, MN 55323-0066 Date received: 377`U 9 <br /> r Street Address: Received by: a� <br /> `;1.i •': 2760 Kelley Parkway Plan review fee: <br /> ►�; •.. Orono, MN 55358 <br /> Total Fee: 7o 7 5 <br /> Main: 952.249.4600 Fax: 952-249.4816 www.cl.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 INFORMATIO <br /> Job Site Address: 5 i14-•1144- LAt , /O,ps,frA <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes o <br /> if yea,a special event permit is required with Police Department end City COURCII approval 60 days prior to the event. Shuttle bus ee/ I <br /> required unless applicant demonstrates sufficient on-afte perking Is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: /f (040 <br /> State License It ....sr ,,, __ ._ Expiration Date. - / D O <br /> Phone: % WI- - 5( • (office) 6/' '75 (cell) <br /> Melling Address: J3 / ' 4l ,41, ,i..i1 e j Cl • <br /> . i s ZIP: /Am <br /> Contact Person: Applicant is: 4 _ =« / Homeowner (Circle One) <br /> Email and/or Fax: /tee kr ifec.i Ail/d'ke, iodrM <br /> PROPERTY OWNER INFO-MATION: <br /> Name; r.;itAk I ' ,.4 • .f , i` ..rr/.: _:,.L.4..-._ /xi - i <br /> Phone(day): Air eern -- . - 6'M*c• .A>rP,7 4e, eG/ [ •�- - .- -'-7 • . 9P <br /> Address: - AiG __C1City: �rono ZIP: ��Gr <br /> Email and/or Fax �� <br /> PROJECT INFORMATION: <br /> Type of Project: I Any earth movement may require <br /> MCWD review&permits <br /> ❑Door(s) ❑Remodel 0 Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑Siding ffiestoratlon 0 Other (specify) Phone: 962-471-0590 <br /> Fax: 952-471-0882 <br /> ❑Re-roof 0 Fire Damage www.minnehahacreek.org <br /> Overall Project Description: _ �•, jC�e /I'j a/ ' /LG•'J%ice+ /__.eof-- <br /> Estimated Construction Valuation of Project(excluding lend) _ >' • <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 ann ipdate our records and records of other governmental agencies <br /> required by law, If you refuse to supply th- .1.rmatl• ,,a plication may not be issued. <br /> (-----) ',, rata. J7• 7- „20 <br /> Z0 'd T Si'86Z-O T S9 H331Aela WO 20: 60 6002—L0-nno <br />