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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> O4 MailiPO Box 66 ng Address: Permit number: 020// 7 5J <br /> /v O Crystal Bay, MN 55323-0066 Date received: 7/28'/ <br /> ,� �!' e .; �, Street Address: <br /> Received by: <br /> Mcg ' ^t;l, _ Gtiti 2750 Kelley Parkway Plan review fee: <br /> +1'i1��4w Orono, MN 55356 <br /> Esz;o <br /> Total Fee: c L/. Ce <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: / <br /> Job Site Address: 7/;‘.-5 /%77 j /,1////,4 ./�jr///G <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 I APPLICANT INF`/ORMATION <br /> Name: ��cr/Y�r / '5 <br /> . '` <br /> State License# 3 ,`)7f Expiration Date: ,3.-3/- .2Di..a <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 76 Z -4/75 - .?fl' 7 (office) 6,42 - 7/(5°-0_53.6 (cell) <br /> Mailing Address: /7 , c (a,2d cV y%L� .42/77 c. izIP: .5:5W7 <br /> Contact Person: A. ei 4 w y 4 �- Applicant is: contr cto)/ Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY ./OWNER INFO/R AT ON: <br /> Name: 6% Les ',/ -t) <br /> Phone (day): Al, -g S—Dc?/5 <br /> Address: //25 4/4/-4 /1/%/0e.) Dr 2/e, City: CJro.e../d ZIP: 55356 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) 0 Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> 0 Window(s) 0 Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> 0 Siding 0 Restoration 0 Other: (specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> `�Re-roof 0 Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: 7 — d/ 6 ';Le_ ��y/-24,.-- 7:;;;._.. 4,--/..;,.._.e 5�� 11" <br /> Estimated Construction Valuation of Project (excluding land) $ /e, 6',4,..--1.'-3— <br /> i. <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 in •rmation is to annually update our records and records of other governmental agencies <br /> re•wired b law. If ou refuse to s _Lel t_- infer atio ,the application may not be issued. <br /> 1 //.:1 � <br /> Applicant's Signature: Date: 7.8 J <br /> Last Updated: 03-01-2011 <br />