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=City of Orono
<br /> ,.Building, Per,mitApplication for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mail ngAddress r/>l"00 75' 7
<br /> fl,N. PO Box 66
<br /> Permit number. i r
<br /> �. Crystal'Bay,MN 55323-0066 Date received: �../
<br /> n " Street Address Received by:
<br /> e4 ,d \ ., 2750,Kelley Parkway
<br /> _i,...,4:1„$ ,� r, Plan review fee:
<br /> °,: v. ,MN 55356;,
<br /> �� � Orono
<br /> Total°Fee: 7 G�
<br /> Main: 952-249:4600 Fax 952.249-4616 www.cl.orono.mn.us l
<br /> This.application form must be completed in full and all required information must be submitte=i
<br /> Incomplete applications will be returned. (Please print)
<br /> ENERALINFORMATION:
<br /> :Job Site Address , O ✓t f 1,. :. ', gh.tie
<br /> Will this be,,a Parade oft"Homes, Flea odelers Showcase.Home or other Display Home? 0 Ye 0 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 ervice will be
<br /> required unless.applfcant demonstrates sufficient omstfe parking is available. 'Non permitted events will not be allows
<br /> CONTRACToR.I APPLICANT INI'ORMATIO
<br /> Name: Alt Tsai 1 ,:'4ry� rrva L�.e
<br /> Siete-License*icense.* �'t 6"3 Q J,, Expiration Date:
<br /> Phone; 7.4 ',.'rsr 1:3 . (office)
<br /> (c
<br /> Mailing Address: _ l 7 3 Pv , � City: /��r
<br /> ': iiN 7ZIP. i ticell)
<br /> Contact Person A Applicant is: •ham- •`iliau I Homeowner (Circle One)
<br /> 'Email acrd/or Fax: ;' Ail S+ ssoy►,re,'csott.1 .-0.4fri
<br /> :PROPERT'Y OWNER INFORMATION:
<br /> ,Name ,,Ti-s't•h $c.4,,'''rir
<br /> 'Phone:(day):4 '` 01 3'rg- . 'v741,
<br /> Address: �' City: ZIP:
<br /> Email and/or Fax
<br /> .PRC!JEBORMATION:
<br /> Type of ProCTjeiNEct: Any earth movement may .quire
<br /> [i Door(s) 0 Remodel _
<br /> MCWD review&peen
<br /> Q U1(ate'r Damage
<br /> -,[Q`.Wndow(s) 0 Re air Minnehaha Creek Watershed Dist ct(MCWD)
<br /> p 0 Storm Damage 18202 Minnetonka+Biv
<br /> 0 Si0 Restoration , Deephaven,MN 5539
<br /> Otfier(specify) Phone: 952-471-059.
<br /> e-roof Q"Fire'Darrrage Fax: 952 471-0682
<br /> ehahacreek.•
<br /> Overalls`Project Description ( df " " /
<br /> Estirnsted construction Valuation of Project:(ex I d � E"
<br /> mg land). . $
<br /> APPLICANT ACKNOWLEDGEMENT
<br /> s • -Agrees to provide all information required or requested by the Building Department;
<br /> •. Certifies that the information supplied;is true andtCorrect to the best of his/her knowledge. The applicant reco nizes that they
<br /> are solely,responsible for submitting a complete application being aware that upon failure to do so,the staff h-. no alternative
<br /> but to reject it-urntihit is complete;
<br /> • Some.o`all of the information fthat.you are asked to.provide'on this application is classified by State law'as ither private or
<br /> confidential Private data is information which generally cannot be given fo the public but can be given to th subject of the
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject o'the`data. Our
<br /> purpose and intended use of this information to an ivallyUpdate our records and records of other govern ental agencies
<br /> required by law,'.If you refuse to ' 'p• y the 1 ``•''� atlon..the application may not be issued.
<br /> . , or
<br /> Applicant's Signature: <.- , .
<br /> '.--.
<br /> Date: �^2'"f/'
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