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FROM,: NOR;HSTA SALESALES � PHONE N0. : 952 544 1643 Jan. 10 2011 05:02PM P1
<br /> " D�
<br /> I /f �
<br /> i Ihi 1 i �'� I,
<br /> Ci of Orono � � �
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<br /> Buildin� Permit Application for Internal Work
<br /> (windows, doors, siding, re-roof, etc.)
<br /> - •��::-. Mailing Address: � / QQd�
<br /> ���"�" Permit number:
<br /> � � PO Box 66 - .- --�---••----
<br /> �°��,y,� ��`�, � Cryscal Bay. MN 55323-0066 Date received: � /
<br /> �R�, �, ° � -�-
<br /> i � � � �.�,':;_ �, StreetAddress: Received by:
<br /> ��,�� � '�� ��'/ 2750 Kelley Parkway Plan review fee:
<br /> .�g o¢6:.i Orono, MN 55356 ,J�' �
<br /> �_.�H ___.. "x 9�
<br /> i _`. --- Total Fee:
<br /> ain: 952-249-4600 Fax: 952-249-4616 WWW.CI.orOnA.mn.us
<br /> his application f m must be completed in full and all required information must be submitted.
<br /> ncomplete applications wilt be returned. (Please print)
<br /> GENERAL 1NFORMATION: y)
<br /> .� Jpb Site Address: � �1,1 (�, _
<br /> ill this be a Parade of Hom s, emodelers owcase me or other Display Home? Yes No
<br /> !f ycs,a spec�al event permi!is roq ied wrth Po/ice Department end C/ty Council approval 60 days prior to the evenk Shutt/e bus service will be
<br /> quirsd unless applic t de�onstrates suA'iclent on-site parking is available. Non-permitted events will not be allowed,
<br /> CONTRACT R/APPl��C NT F. RMATION:
<br /> Name: �-�� •- C�I'l.�
<br /> _....,�- � _
<br /> State License# , ,^� Expiration�Date; �
<br /> Phone: _ _ (office) �µ" (cell
<br /> Maili�g Add ess: �_,_� City: �Ip�
<br />� Contact Pe on: _ _ � Applicant is: Contractor / Homeowner (Circle Ono)
<br />� Email and/or Fax; ___,
<br /> PROPERTY OWNER FORMATION:
<br /> Name; ��.�u�i P.n S _..
<br /> Phone(day): g��, �.�e�_ �� � w"'�
<br /> Address: f�f Z S (�����k�_d�c� City: 1 �,�c� ��-C, ZIP; C""�?,�1
<br /> Email and/or ax �_�Q�,E> �m4�d,��,,,�,� �—��,,,,
<br /> ' PROJECT INFORMA710N:
<br /> Type of Project: ��^ � Any earth movement may require
<br /> MCWD review&permits
<br /> � ❑Door(s) (�Remodel ❑Water Damage
<br /> Minnehaha C�eek WaSershed District(MCWD)
<br /> ❑Window(s) � ❑ Repair ❑ S�orm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> � �;�sidin9 Cl Restoration ❑Other: (specify) . Phone: 95�-d71-Q590
<br /> Fax: 952-471-0682
<br /> I ❑ Re-�oof ❑ Fire Damage www_mirinel1ahaCrer�k.,org
<br /> Ove�all Project Description: i ,, : ���4,_ '�'�,�� � _,; �'�,,,�,�,��-f�ms/
<br /> vEstimated Construction Valuation of Project(excluding land) $ 3r-� �- �
<br /> --.� _.._..,�_---�n7�s
<br /> I
<br /> APPLICAN7 AGKNOWLEDGEMENT:
<br /> � Agrees t provlde all information requ�red or requested by the Building Department: ~^ ��
<br /> I
<br /> • Cefifies that the i�formation supplied is�rue and correct to the best of his/her knowledge, Thc applicant recognizes that they
<br /> are solely responsible for submitting a cqmplete applicaYion being aware that upon failure to do so, the staFf has no alternative
<br /> but to reject it until it is complets;
<br /> • Some or all of the inFormation that you �fe asked to provide on this BG�plication is classified by State law as either privat0 or,
<br /> confidential. PrivatE data is informdiionlwhich generally cannoS be givan to the public but can be giVen t0 the subject•of the
<br /> data. Confidential data is information which generally cannot be given to either the public or the subjeCt �f the data. Our,
<br /> purpose ar+d intendad use of this information is to annually update our records and records of other governmental agencies
<br /> requir d b Iaw. If you r�fuse to supply the inform2tion,the appliCation may not be ISsi�ed_
<br /> _.. .:..__.. �,L�—_..... _.
<br /> I � /
<br /> Applicant'sSi nature: 1C� ��/d��� _,.,_ Date: 1�����__�,� .
<br /> Last Updated: 05-Od-2009
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