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City of Orono 5. 50 <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: / <br /> g,0 � PO Box 66 Permit number: ��r/� d�f0 <br /> O Crystal Bay, MN 55323-0066 Date received: aild1/4 <br /> Received by: <br /> Street Address: T 8 <br /> titi 2750 Kelley Parkway � L� <br /> o Plan review fee: <br /> Orono,rono, MN 55356 <br /> O//—DOD4o3 <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 nsub�ed. �� <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: (� <br /> Job Site Address: Lc*A ?e..k+ Rci <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 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: Levy B rbs . t-k Pvte_s <br /> State License# 3 a 5555 Expiration Date: 3- 31 - 001 a <br /> Phone: 459-'14 e- 3'l 25.3 (office) (cell) <br /> Mailing Address: t Soia {i-wY -I Cit : _ Ivw a-}onka ZIP: $S3&4S <br /> Contact Person: Dcvins inn a.irk Applicant is: 4 ontractor / Homeowner (Circle one) <br /> Email and/o&It 952.-94-ka- to 68 <br /> PROPERTY OWNER INFORMATION: <br /> Name: 3,1' La(r►rn Ro�du►r•z <br /> Phone (day): fo1Z-"'lt9 -3S' <br /> Address: 2a•c5a 1&[ Lf .yep-+ . Ri City:Ecce lscor ZIP: SS 331 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) Q(Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: ecksetrviev-.(. �' � Q ,ck , Gln f1sc3 yvt rite� -�tv+¢�luce <br /> Estimated Construction Valuation of Project(excluding land) $ as,orb <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 supply the information,the application may not be issued. <br /> Applicant's Signature: Date: oD©(I <br /> . <br /> Last Updated: 05-04-2009 <br />