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� � -. <br /> City of Orono <br /> Building Permit Application for Internai Work <br />' (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permit number: Q�7'—�� � <br /> ��O�� Cry sal Bay,MN 55323-0066 Date received: 9 � O�j <br /> a, Street Address: Received by: <br /> �,� y GtiF , 2750 Kelley Parkway Plan review fee: <br /> t�.E�og� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 wwrw.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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: _�,3�5 e� bi-r�y��� C�ay <br /> �II this be a Parade of Homes, Remodelers howcase H e 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 applicanf demonstrates s�cient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br />- Name: ��e��,�,, � L��s <br /> State License# Expiration Date: <br /> Phone: l�5� -�73-�69/ (office) (cell) <br /> a Mailing Address: _�hov� Ci : ZIP: <br /> Contact Person: Applicant is: Contractor / omeowne (Clrcle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: D�`cksoni (,tl 9/ J hvra.h 'V✓�. Lew,�S <br /> Phone(day): 9,��-y73_ .��5/ <br /> Address: o`�3.h3 i¢6�v�y alo>-i Gt/oui City: �+anc, /-�.,� ZIP: .�,�'>',S'-Zo <br /> Emailand/orFax jj�.er,v,'s �L�9 @ qa�/. c�-, " <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 /> Fa�c: 952-471-0682 <br /> I�Re-roof ❑ Fire Damage www.minnehahacreek.or4 <br /> Overall Project Description: <br /> _Estimated Construction Valuation of Project(excluding land) $ /���-v�,Gb <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 altemative <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 govemmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: v'��� �� G�eG� Date: �/�a/o J <br /> Last Updated: 05-04-2009 <br />