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Cit of Orono 1 '�,�
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<br /> Building Permit Applicatiorr for Ir�ternal V�/ork
<br /> (windows, doors, siding, re-roof, etc.) �
<br /> __..,—_.. MHilrng Addr�ss: Permit number; c�Z� �/ ` d0 �i� I
<br /> ��' PO Box 66 ---�'J /
<br /> r � ��`�..
<br /> � � �' Crystal Bay. MN 55323-00B6 Dat receiv�d: l 1�'
<br /> //0 O\, .
<br /> ;, �,N. , I
<br /> RE�ived b�: �
<br /> ��a �� �-�� �, Streof Address: I
<br /> ��� � '�� •a>�y G�� 2750 Kelley Parkway planlr�view fee; _ ,_,. I
<br /> `�,;�q�. og�.;�� , Orono, MN 55356 �� • �r
<br /> �•:_:-....Es� -
<br /> .._._... _:... To Fee: oCsJ
<br /> M a i n: 9 5 2-2 4 9-4 6 0 0 Fax; 952-249-4616 www ci.orono.mn.us ,,,�
<br /> �� This application form must be completed in full and all required inform� on must e submitted. I �
<br /> Incomplete applicatio�s will be returned. (P/ease �int)
<br /> GENERAL INFORMATION: ��
<br /> Job Site Address; G � _ _
<br /> Will this be a Parade of E-�omes, Remo elers owcase Home ar other Display Home. ❑ Yes No
<br /> If yes,a specra/event p�imR fs required wrth Po�i�Deparrment end Gity Counc�i approval 60 days prior to tne eve t. Shutt�e bus s�rvi wlll be
<br /> required un/ess app/icant d�monstrates suNicient on-sit�paik/ng is availeb/e. Non-permllted even�s wi I not bm allowetl.
<br /> GONTRACTOR!APP ANT NFORMATION:
<br /> Name: ._..�_�,,S��a_ f'.p.� "_ �C.i2�L.o r ..._...,.----- -.._.�,,.r••--------- �...,...._._
<br /> State License# Ex iration Date�. _„_.,_�___ ,.,
<br /> Phone: -- (office) _._ �M� ___�..(cel�_
<br /> Mailing Address: �� M� City: _ _ z1�: ____
<br /> Contact Person: ^ ����,_^,^ � Applicant is: Contractor l� Homeowner (Cirelo One�
<br /> Email and/or Fax' �.,.,�,.�---- ,..._. — ---------�---.....,>.. -
<br /> PROPER7Y OWNER FORMATION: �
<br /> Name: �.�'�r- (til�r_C.._.. --- — _�_._�.._..� ---
<br /> Phone(day): ;y � � �
<br /> Address: �+�� �y�j r _ Gity: L,c�,�l��—_ ZIt?:,,5� I
<br /> Email and/or Fax �r,,;�} �� i,������f rn,n, _. -- -...-•.,..• —."'—
<br /> PROJECT INFORMATION: -
<br /> IType of Project: ��M �'� y� Any earth moveme�4 may raquire���� � `
<br /> � MCWD re4iew 8 permits I �
<br /> i i��oor(s1 [�Remodel ❑Water Damage �
<br /> � Minneh�ha Gre�k Watersh�d District(MCN1�) � �
<br /> j [�Window(s) ❑ Repair ❑Storm Damage 1820�Minnetonk� Blvd �
<br /> � �eephave�i, MN .55391 �
<br /> , �Sic3iny [� f2estoration � Other. (specify) Phone: 957_-471••059U
<br /> Fax� 952-471�06$2.
<br /> � ❑Re-roof ❑ Fire Damage '_ �!�!W„;m�nnehahaCr��k�org �`�
<br /> i. __ ..— ., r��..
<br /> Overall Project Description: �,� ,� L����, in���`,������-����¢+��� ��/�9��
<br /> _ Estimated Gonstruction Valuation of roj�ct(excluding land) �$a�-���,„,l � --..�,_.----
<br /> — '"T
<br /> �PPLICAN7 ACKNOWLEDGEMENT: __.,_ __....,..,.. _._—__�.�....___�
<br /> . Agrees ip prov'tde�II information required or requested by the Building Deparfm�nt;
<br /> ' • VCertifi�s that the informaYlon Supplied iS true and cof�eCt to the best of his/her knowledge. TFi2 ap�)licant reCognizos ttiat they
<br /> dre solQly �espOnsible tOr Submitting a COmplete application being aware that upon failure to do sv, the st�ff has no altemative I
<br /> but to raj�ct it untif it is complete;
<br /> ( • Sqme or all of the information that you are a5ked to provide on this application is �laSs�fiad by St2',� Idw as either priv�t� or I
<br /> � confidential. Private deta is information which generally ca�r�ot be given to the public but c�n be given Yo the subject oF the j
<br /> i data. Confidentidl data is information which g�3nerally cannot be piven to either [he public Gr I.h�' subjer,t of thF data. OItr i
<br /> I purpnse and intGntled use of this information is to annually update our records �nU recorcis of otYier govemmenttil �gencies �
<br /> I required_by law,._If you refuse lo supply the information,_the application may not be�ss�{�=d. . , ... . .......... . ...__._.. . .
<br /> Applicant's Siynature _.___.�,J��.�� Dale: L�'.lIJ__...._..........__. .---.. ....._-.�..
<br /> c..:.r�updai��r o;,o� 200�
<br /> Zd Wd90:0T TZOz 60 'G'a� �b9Z bbS zS6 : 'ON �NOHd S���dS��tiS �fd1S l�ION : W0�l�
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