Laserfiche WebLink
MF:Y/,1E!2014/FRi 04; 24 AM Elder Jones Building rA� No, 952 854 �909 P, 002 <br /> City of Orono <br /> �ui�d�ng �ermEit Application for lnterna[ Work <br /> (windows, doors, siding, re-roof, etc.) <br /> MaililtgAddress: permit number: �DI � <br /> O-�,�,�Q PO Box fi6 _ <br /> Crystal Bay, MN 55323-Op66 Date rBCeived: �- <br /> �' ' - Received b <br /> ,� �p��,�.��. � StraetAddress: Y� <br /> � .��,.'`i1.� Gti 2750 Kelley P�rkway P3an reviewfee: <br /> '�� '�:�, "�•�.w Orono. MN 55356 <br /> ��sfY� <br /> Main: 952-249�4600 Fax: 952-249-4616 www.ci.orono.mn.us � Total F2e' I ��./} <br /> �, �.� <br /> This application form must be comple�ed in full and all required infdrmation must be submitted. <br /> Incomplete appEications will bQ retumed- (P18ase prinf) <br /> GENERAL 1NFORMATION: �,�� ��Q w � G]� a � � / <br /> J�b Sife Acldress: �'� l V <br /> Will this be� P�r�de of Homes, Remodelers Showcase Home pr otl�er DiSplay Home? 0 Yes ❑ No <br /> !f yes,a spec/a/evant perm;t;s required with Pollce Department and City Counci!approval 6o days prior to the event. Shutfle bus service will be <br /> fequiled unless�pplitarlt d6mon3trJtes 5uiiicienf on�site parking is available. Non-peYmitted evenfs wi!!not be�a1/o�✓9d. <br /> CONTRACTOR/APPLfCANT INFQRMATIQN� <br /> Name� ,� ��'� 31/S"• � a�7 <br /> 8tate License# '�HD At-Hpz711e SeT'Vi.Ce� �c, n�y, <br /> Phone: x 2690 Cu�nberland�kwy, S�e 300 (cell) <br /> Maifing Address� Atlanta, CrA 30339-3913 ZIP: <br /> Contact Person� �,lc#GR2.6gZ�7 Pl�,. 763/542-$$26 �omeowner �c�����o„�� <br /> E��ail and/or Fax: <br /> ; <br /> PROP�RTY�WN�R INFO MATjqN: M Q L U S��} <br /> Name: ('4 ff" � '� U <br /> Phone(day): QS� Y7G - �S7 <br /> Address: 7 0 /` 0 W /Z n Q � Ci : L on �Ct �� ZIP: �� �a 5 L <br /> Email and/or Fax <br /> PROJECT IN�ORMAT[ON: <br /> , Type of Project �—� � Any earth mo�ement may require <br /> MCWD review&permits <br /> �Door(s) ❑ Remodel ❑Wat6r Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> "�IQ(indow(s) Repair ❑Storm Damage '18202 Minnetonka Blvd <br /> Deephaven, MN 5539'E <br /> ❑Siding ❑ Restoration ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-47'E�0682 <br /> [] Re-roof ❑ Fire Damaga www.minnehahaCreek.or <br /> O�erall Pro�ect Descript�on: (,.� �/'� � � /� (,�, Q,� S l�} � �J O t� Ct'S <br /> �stimated Construction Va[uation of Project(excfi�di g land) $ � �l � Q� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide 211 inform�tion required or requested by the Building Department; <br /> . Certifi�s that th0 information Supplied is true and correct to the best of his/her knowledge. The applicant recognizgs that th6y <br /> are�Solely fesponsible for submi�ting a compEete appiication being aware that upon failure to do So, the Staff has no alternative <br /> but to reject it untif it is compfete; <br /> • ' Spmg pr all of the informaUon thaf you are asked to provide on this application is classified by State law�s efther pnvate or <br /> confidentiaf. Private data is information which generally cannot be given to the public but can be given to the subject.of the <br /> data. Confider�tial data is informafion which gener�Ily cannot be yiven to either the public or the subject of tFte data. Our <br /> purpose and intended use of this information is to annually update our records an� records of other govemmental ag�ncieS <br /> re uired b faw. If ou refuse to suppl thg fnformation,the a IiCaYion m2 nUt be issued. <br /> Applicant's Signature: � Date= � l� L ( �y <br /> Last Updated: OS-04-2009 <br />