2009-00650 - PERMIT VOIDED - Laserfiche WebLink

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, . City of Orono ��S�o� Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: D� � �,�,�. PO Box 66 Permit number: Q ;, Q Crystal Bay, MN 55323-0066 Date received: �� a ,� ��r �,�� Street�ddress: Received by: 1� ;;- �',�,t� a '� �ti�" 2750 Kelley Parkway Plan review fee: 9g.E�*v Orono, MN 55356 n � Total Fee: � �j /��7 Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us __� � ��- This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: Job Site Address: t�Op �,�; 1�,��„�� Will this be a Parade of Homes, Remodelers Showcase Home or other 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/AP,P`LICANT INFORMATION: Name: t1�c,l.�uw.ti;rk .�.��c�.rs 1�e� State License# ?l� �3i3 Sy� Expiration Date: 3�;i�„� Phone: - - _ g� office �? - 29Z-p4�3 cell Mailing Address: � Cit : � �,1(,rt ZIP: $'-- Contact Person: J�w� ��c,� Applicant is: ontrac / Homeowner (Circle One) Email and/or Fax: ��w�, ,�,�LsaS [j �n��:'�.w�o.,rk - b��c�ws � C4� PROPERTY OWNER INFORMATION: Name: >�v�v�w �ww.�, Phone (daY)� )S L - j�o�� - 91u6��-�-�— Address: (�c�c:� �,Lc► 1 s Ic+�d1 CitY: �4��nc> ZIP: Email and/or Fax �1r�ti�e�uler � t�alle� c�,M PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review 8�permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑ Siding ❑ Restoration �Other: (specify) Phone: 952-471-0590 ,-, . Fax: 952-471-0682 ❑ Re-roof ❑ Fire Damage Ut.� � G�iS www.minnehahacreek.orq Overall Project Description: � 'x� � i�J , u Estimated Construction Valuation of Project(ex ding land) $ �C 0� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; � �a�C�- • Certifies that the information supplied is true and correct to the best of his/her knowledg ( y are solely responsible for submitting a complete application being aware that upon failur �� J �,n p � e but to reject it until it is complete; l�'UV lL • Some or all of the information that you are asked to provide on this application is clas: n� �/��,� �r ��v t.v confidential. Private data is information which generally cannot be given to the public e data. Confidential data is information which generally cannot be given to either the p �1�Gry V1 1 v� " ' ir purpose and intended use of this information is to annually update our records and re� � s re uired b law. If ou refuse to su I the information,the a lication ma not be issued ApplicanYs Signature: Date: Last Updated: 05-04-2009