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Jun 28 11 08:22a Mike DeNomme Constr. Inc. 952-955-3300 p.2 / City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: c:›7-0l/— 6- j C* PO Box 66 ez, c/// �/ :•4?‘ O` Crystal Bay,MN 55323-0066 Date received: 4, �s��', i,: t.!) Street Address: Received by: 7-7 �,� 4.1..1110.- • 2750 Kelley Parkway Plan review fee'. \�Rc:';',.7 Orono, MN 55356 -7 \ o� Total Fee: 0 / � 7, 7,.$ Main: 952-249-4600 Fax: 952-249-4616 www.ci.ororto.mn us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: _ / Job Site Address: /090 kikierr INFORMATION: ,, �12)/7c / ,t) Will this be a Parade of omes, Remodelers Showcase Home ofother Display Home? ❑Yes No 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 required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPPLLIC N INFORMATION: y�� _ Name: !/1 e _1)e /Amine �. i6 "` �it2 27C', State License# 79 Expiration Date: 3/3/ ..—Zo Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1976 , Phone: 1-12- 9 ' ��-,1, (office) 2-— --327 4 (cell) Mailing Address: Ta / ,,,ui i� City: /( ZIP: • Contact Person: g4' e D_, p,�� Applicant is: ontracto Homeowner (Circle One) Email and/or Fax: Gc-2_ 953--3300 PROPERTY OWNER FO MATION: Name: fa ct- .2il4 . 2 7_4gn Phone(day): Z-7,3 —77 a / its' P// Address: /,0q0 ai, w'hdOt 7,^4;/ City: 757(./ ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(s) ❑ Remodel 0 Water Damage MCWD review& permits: Minnehaha Creek VVatershed District(MCWD) ❑Window(s) ❑ Repair 0 Storm Damage 18202 Minnetonka Blvd ❑Siding ❑ Restoration 0 Other: (specify) hone: Pven, MN 55391 Phone: 952-471-0590 ie-roof ❑ Fire Damage Fax: 952-471-0682 / www.minnehahacreek ore Overall Project Description: re roe f L Estimated Construction Valuation of Project(excluding land) $ /rvi QOO,Q O APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department, • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information,the application may not be issued Applicant's Signature: "11,-y_, yr-4-6' Date: 1/,_;),S� // 1 Last Updated: 03-01-2011