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City of Orono 24. -- /,S1‘25---
<br /> I Building Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.) QQ 91C)
<br /> Mailing Address: Permit number: -1.0 r 0'r�/��
<br /> 11)C).
<br /> ,�,� PO Box 66 �b
<br /> 44 Crystal Bay, MN 55323-0066 Date received: /0/7/0
<br /> Received by:
<br /> i �,r;, ti Street Address:
<br /> �c, ti 2750 Kelley Parkway Plan review fee:
<br /> f,•a�I,, ��G Orono, MN 55356
<br /> t`4EsHo0
<br /> Total Fee: /96, /
<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: `-1 5 G✓/z-e-eGJ (///) ze
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 7 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: 7-761014-7.4-1Z:,v4:) ,4'si //vc_ .
<br /> State License# �p,-.2Y-/q1 Expiration Date:
<br /> Phone: 9S2 - 0 -67 7) office) (o<Z 75-9- Spiv (cell)
<br /> Mailing Address: 2673 t,.r. e',/„4-y2,¢7W £Ls-/j, -;--o City: .n!' ,,gx.,ff ZIP: --6
<br /> JS ,
<br /> Contact Person: -739j S72-/Eyt Applicant is: con racto / Homeowner (Circle One)
<br /> Email and/or Fax: z�/2?,-: c- -,-*,�,-6 .,,,.,2_ j- ! L,o;,,._
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: , i2_UC X4,4-cd d TfzNe iL>4/
<br /> Phone (day):
<br /> Address: _S;4--1-1-7, City: ZIP:
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review& permits
<br /> ❑ Door(s) ❑ 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 /> We-roof E Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description: 7-4-Aix ULA 5i , _/zJdr - 23
<br /> Estimated Construction Valuation of Project(excluding land) $ /o -
<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 /> •
<br /> Applicant's Signature: <� Date: /v 7 /v
<br /> /9
<br /> Last Updated: 05-04-2009
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