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(oZ/ 1,j,i( <br /> City of Orono/Li/4A Buildingb'- <br /> Permit Application for Internal Work O5 <br /> pp 1.33 T <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: ad//—eV .>8 <br /> 4::::3;,_,0_-_____4,._ <br /> j,0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: Vt9 // <br /> I i,%--, , � Received by: <br /> , 4 . , ?� A,, Street Address: <br /> 1�, a'1 M ti 2750 Kelley Parkway Plan review fee: # TA3,39 <br /> `� iessoOrono, MN 55356 ©f/-0-V ?57 <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: ,l <br /> Job Site Address: I 31 °J L.) . 1—c'/vim +t - O(' D/"t <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑ Yes El 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: <br /> Name: Lc�l-ce.. CO u�► e,-1L-- <br /> State License# ZL 17 O rj6,7 rk / Expiration Date: 3 / 3 l 1211 <br /> Lead Certification Number: a V, ft V( q Expiration Date: <br /> (for work on homes that were constructed prior to 1978' <br /> Phone: (office) (cell) <br /> Mailing Address: ' YJ3`-1 ce044 $. City: tXteK Dr- ZIP: 5557 1 <br /> Contact Person: �, ,(.,(,L Applicant is: Ctrac1o) / Homeowner (circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): 9 2`t 7L- 71 2, ) <br /> Address: 1 9 3D Q , ice r" i\�t I v`✓ A ' Y"1 K1 City: Oc,:;n ,; ZIP: 3 9.:.Email and/or Fax ` <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) g Remodel ElWater Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> I=ISiding 111Restoration 111Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> El Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq_ <br /> Overall Project Description: K't 6A ' y / hi--k,\)\,1C`-AA, ;�c\M <br /> Estimated Construction Valuation of Project(excluding lan ) $ 13S U 1 <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 whi generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of . in ormat. ' is to annua ..:.te our records and records of other governmental agencies <br /> required by law. If you refuse to s pp y the 'sr .tion,t'e applicati•n may not be issued. <br /> Applicant's Signature: 1� Al Date: �� 'Z °� ZG' , <br /> Last Updated: 03-01-2011 <br />