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a ` " ; City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: oR0/D-et7<1.35 <br /> 0‘(3,�0 Cr Box 66 <br /> .1-" Crystal Bay, MN 55323-0066 Date received: 0l7/2-d/e) <br /> A , Street Address: Received by: -7 7 <br /> I. , i. h � G4. 2750 Kelley Parkway Plan review f : <br /> bgr. Hog4* Orono, MN 55356 <br /> Total Fee: �. 3_ <br /> O� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 42- <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: 0 7s / ,4u,i /'l' ,�Q4 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,l 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 will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION / r <br /> Name: �, _ rv► � ,! .!(�,:.. gL'viJ%c-� <br /> State License# ,® A1S_3 3 Expiration Date: '/S//2 0/ <br /> Phone: Sa -F23---09 Zo (office) 6 /2 -7r9 6-ingS— (cell) <br /> Mailing Address: e 5-4/115 s'-- /t/t0� l � City: c -) ZIP: 5'5-,T y6 <br /> Contact Person: �a/;,, /Z'�a f .- Applica is: Contracto / Homeowner (circle one) <br /> Email and/or Fax: �''e,,,,,,, 4a.�c )4- ice,.,/j.:, • S-e rlJ .P Co f <br /> PROPERTY OWNER I FORMATION: <br /> Name: / �/ GQ / � _ <br /> .s.6;dz. <br /> Phone(day): /2 - 2 1/5"--,s?_;r? _ <br /> Address: 2 c,7 s- C-JQh k e✓ /-/;)/c / ) City: Or©h.c, ZIP:._ S,,S'S'"6, <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> 0-Boors) ❑ Remodel 0 Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) 0 Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding 0 Restoration ther: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof 0 Fire Damage /.Je'c./--- www.minnehahacreek.orq <br /> Overall Project Description: 6 <br /> Estimated Construction Valuation of Project(excluding land) $ /i 000 l <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 info.... " which generall not ._ given to the public but can be given to the subject of the <br /> data. Confidential data is .• •rination , ich •:'era . p o be given to either the public or the subject of the data. Our <br /> purpose and intended ;,- of this inform:tio I to/.n .. . ly plate our records and records of other governmental agencies <br /> r-.uired b law. If •a refuse to supply t e' . !, lo/ a .).lication ma not be issued. <br /> /r/r„// <br /> Applicant's Signature: ; Date: "` 2f /J7 <br /> Last Updated: 05-04-2009 G <br />