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Oct-18-1011 01:55pm From-CITY OF ORONO +9522494616P.002/002 F-671 <br /> , ' ' ' • ted)L: n • <br /> City of Orono - In <br /> • Building Permit Application for interna Work .- ' . .. <br /> . (windows, doors, siding, re-roof, etc,)• . <br /> �_y MailiPO B 56 Perfmltrwmber: .ae,'414D <br /> `�� Crystil Bay,MN 55323-0068 Date rs3ceiwn J <br /> 4 Street Address; Received by: <br /> 14,(7) <br /> R .:� i 2750 Kelley Parkway Rlan revieur firms ' • <br /> .1x‘,.1.. .. Orono,MN 55388 <br /> • TotafFee: p2 .. f / ,^'ti <br /> Main: 952249-4600 Fax 952` 249.481E MAN-ci-orono.mn-us <br /> Ibis application form must be completed in full and all required information must be submitted. /f'1 AL <br /> , incomplete applications will be returned. (Please pint) <br /> GENERALINFORMATION: <br /> JOb AIM*Wives: • 3Th S LAIdC lis' <br /> Will this be a Parade of Homes,Remodeiera Showcase Home or other Display Homo? Yee No' , . <br /> rya%especialewtit permit is zequlred with Pollee Department and Cry.Council eppieval 80 days prior to Vie event. Shuttle bus.servi-e wig be <br /> .egnbad unless appllesm demonstrates&Ufic ent On le panting is avertable- Nonpermttted events will not be auowadl <br /> CONTRACTOR/APPLICANT INFORM•TION: ' <br /> Name: - %. .a 1-A ! , <br /> State License# , : --ti ,sr Expiration Date: <br /> Lead Certification Number: NAI- 1051:42, _ _ Expiration Date: its its <br /> (for work an hams that were constructed prior to 1978 <br /> Pttgne: 1L -i 4 Q (office) (e - ap_ (cell <br /> Mailing Address: ._Loa - c .,ta., 1i., la' 4111, City: ' ...,, .•4 ZIP: - - • <br /> Contact'Person: ' . ,a ck. q Applicant is: •ntr ccto I Homeowner lCl, to one) <br /> Email end arFaX 'I\ ' 'r , - 1, ' t r 1A• 1 ' .I♦. li 11 <br /> PROPERTY OWNER INFORMATION: <br /> Name . . ._ . \>-Ar c lot -- . ' <br /> Phone(day): old- '+ �� ' `>! , <br /> Address:. a 44. g.lr rytr ,`bS c �lnb- zip: 3q'I- __ <br /> Email andlor FaX <br /> PROJECT-INPORMATION: . _ , <br /> Type of Prglect Any earth movement may require <br /> ❑Dvor(S) ❑Remodel ❑Water Damage MCWD review&permits: <br /> Mlnnenaha Greek watershed District(MCWD) <br /> D WindOW(s) 0 Repair Q Storm Damage 18202 Minnetonka Blvd <br /> Siding 0 Restoration ❑tither. (specify) Deephaven,Mill 66351Phonrs: 952471-U590 <br /> Q Re-roof Q Fire Damage _. - _ Fax 952471-0682 <br /> yyuw_rminn baaharreek_arr7 <br /> Ovarial(Project Description_ VIS-1116.1.,=i-W -yam Ce wr . <d <br /> Estimated Construction Valuation of Project(excluding land) S M, . <br /> APPUCANT ACKNOWLEDGEMENT: _ <br /> • Agrees to provide all information required or requested by the eullding Department; <br /> • Certifies that the information supplied is true and correct to the beat of his/her knowledge. The applicant recognizes that they <br /> are solely responsible far 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 ether gcvemmenlal agencies <br /> -.ulred • law. If ou = .e to <br /> su••I the information the:••Iica on ma not be -su •. <br /> Applicant's Signature: !_b A A Date: _..11.4__ ______ ____ <br /> Last Updated: 03-01-2011 ' <br />