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J��n, 17, 2011 11 ; 48AM Giertse� Company No. 1611 P, 1 <br /> . � � ���,� <br /> City of Orono � �_ � 5 <br /> Build�ng Permit Applica <br /> �ion #or lnternal Work � �� � � <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permlt num6er: 011—v� 0 <br /> O�Q,�.O PO Box66 <br /> Crystal Bay,MN 55323-0066 Date reoelved: � <br /> Street Address: Reoeived by: <br /> z750 Kelley Parlcway Plan reviewf�e: <br /> ��qk,�� o$�� Orono.MN 55356 ,l. <br /> Total Fee: I � � , �U <br /> Maln: 852-249�600 Fax: 852-249-4616 www,ci,QrQno.mn.us <br /> 7his application form must be completed in full and all required informatlon must be submitted. <br /> Incomplet�applications will be returned, (Please print) <br /> G�NEI2AL INFORMATION' ,. , <br /> Job 8iFe Address: � � �- �� b� <br /> Will this be a Parade of H�mes,Remodelers Showcase Home or other Display Home? Yes ' No <br /> lf yes,a speciel eVenF permlf Is required with Police DepartmenC end City Coundl appmval 60 days prior to the event, ShuPf►e Dus servlce will be <br /> requl�ed unless appllcant demonst�tes auf/icrent on-sire perking Is avallable. Non•permitted events Will not 0e alfoWed. <br /> CONTRACTOR/APP�ICANT INFORMATION: <br /> N�me� , <br /> State Llcense# �xpiratlon Date: '3 iv <br /> Lead Certification Number: i � Expiration Date: <br /> (for work on homes that were constru fed prlvr to 1978 Cell <br /> Phone: - 6-�1� � (o��e) �b -2 —Dk�► �,t ( ) <br /> Malling Address: e. Clty; ' zlp: <br /> Contact Person: Applicant is: ont actor Ho OWflef (Circle One) <br /> Email and/or�ax; ��`=��A -fl�j j,� <br /> PROPERTY OWNE f FORMATION• <br /> Name: �I 5 <br /> Phone(day): � � <br /> Address: Y� City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: Any esrth movement may requlre <br /> MCWD review 8 permlts: <br /> ❑Door(s) ❑Remodel ❑watar Damage Minnehaha Greek Watershed Dlstrlct(MCWD) <br /> ❑Wlndow(s) ❑ Repair ❑Storm pamaga iB202 Minnetonke Blvd <br /> beaphaven,MN 55391 <br /> ❑Siding ❑Resloraiion ❑Olher:(specify) Phone; 952�71-0590 <br /> .�,�-rooF ❑ Fire Damage Fax: 952-471-0682 <br /> n wv�w rpinnehahacreek.om <br /> Overall Praject Deacriptlon: <br /> Estimated Conatructlon Valuation of Project(excluding land) $ '� 0 � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provide all inFormation requlred or requested by the Building Depariment; <br /> • Certifies lhat the information supplied is true and correct io the best oF his/her knowledge. The applicant recognizes lhet they <br /> are solely responsible for submilling a complele applica�lon being aware lhat upon faflure to do ao,ihe slaff haa no alternaliva <br /> but to reject it unlil it is complete; <br /> • Some or all of lhe inFormation that you are asked to provide on this appllcalion ie classified by Stale law as eilher prlvste or <br /> confidential. Prlvate data is information which generally cannot be given to the public but can be given to the subject oF tha <br /> data. Confidentiai data is informatlon which' ly cannot be given to elther lhe public or lhe subjecl of lhe da1a. Our <br /> purpose and fntended use of this informatio is i a ually updale ouP records and records of other governmental agencies <br /> re uired b law, If o�ref to s I th i o m ion, he a lioation ma not be issued. <br /> Applicant's Signatute: Date: � <br /> Last Updaled� 03-01-2411 <br />