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�5�3`{ , � City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) �O� Maill O��. Pertnit number: O O C��Y�MN 55323-0066 Date received: � Street Address: Received by: � 2750 Kelley ParkwaY Plan review fee: �g��' Orono,MN 55356 Total Fee: Main: 952-249-4600 Fax 952-249-4616 www.ci.orono.mn.us This applicadon form must be completed in full and all required information must be submitted. Incompletie applications will be retumed. (Please print) GENERAL INFORMATION: I r'.� ' Job Site Address: ��% � �.�f�U��C', �"��/ Will this be a Parads of Homes, Remodelers Showcass Home or other Display Home? Yes No !f yss,a spede/evar►t pem�it!s�equired wlth Ao/lc�e Depaibnent and Gty Councll epproval 60 days pnor ro the e►rent. Shuttle bus servioe wdl be requlred uMess eppUcant demonsbetes sulflderrt on.slte pe�ldng is aveilable. Non-pe�mitted events will not be albwed. CONTRACTOR/APPUCANT INFORMATION: � Name: /yl��G✓l�� ObF� ,/�� l,✓'�►�O�,.d Ln� State License# ,Z p D/p a 7 7 Expiration Date: �3/3/ � �t a Lead Certfication Number: Expiration Date: (for w�rk on homes tlwt wsre conshuc�s�prlo�to 1978 Phone: 76.3-�il a� 7-9 G9(� (office) �6 3 o�g0- �.3a � (cell) Mailing Address: ,S'/ r-�,f,1r' Cy�' City: QP� �c ziP: S S 3 6 Y Contact Person: �pryn.y �„dP�b••� Applicant is: n or / Homeowner �cMa.o�.� Email and/or Fax: ')63 — y �7— �00� PROPERTY OWNER INFORMATION: Name: Phone(day): Address: �]�, !� �5'/L�F`C. �� City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Pro�ct: Any sarth movemsM may requfre ❑Door(s) ❑Remodel ❑Water Damage MCWD roview 8 psrmits: Minnehaha Creek Watershed DisUict(MCWD) i ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑giding ❑Restoration ❑Other:(specify) Deephaven,MN 55391 Phone: 952�71-0590 (�Re-roof ❑Fire Damage Fax: 952�71-0682 www.minnehahacreek.orq Overall Project Description: Estimated Constructfon Valuation of Project(excluding land) S �`3` APPLICANT ACKNOWLEDGEMENT: Agrees to provide all information required or requested by tlie Building Department; Certifies that the inf�ortnation supplied is true and correct to U�e best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it urnil it is complete; Some or all of the information that you are asked to provide on this application is dassified by State law as either pnvate or confidential. Private data is information which generally cannot be given to the puWic but can be given to the subject of the data. Confidentlal data is infortnaUon which generally cannot be given to either the pubtic or the subject of the data. Our purpose and inbended use of this infortnadon is to annually update our recorcJs and recoMs of other govemmental agencies uired b law. If u refuse to su the ir�formation the a ication ma not be issued. ApplicanYs Signature: Date: 5 'l '"�� �t upd�cea: os-o�-20»