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MAY/31/2015/SUN 09: 59 ?� Elder Jones Building FAK No, 952 a54 �909 P, 002 <br /> ' City af Orono <br /> ` Building Permit Appiicatian for fnternal Work <br /> (windows, doors, siding, re�roof, etc.) <br /> Mailing Address: Permit number: �C 1 �'"e?C�r� � <br /> �g,�,� PO Box 66 _ <br /> I�� a�, Gystal Bay, MN 55323�0066 Date received: �a� ? <br /> I t:,�,,.� <br /> II1�} ^��>�:t-f� SfrQet Addre�ss_ Received by: (Z� FC <br /> `\�} :�S'�r'%Mtr..'ri�^ � I <br /> � ,�";,��;�',N;�p ti � 2750 Kelley Parkway Plan review f88= ��i � <br /> '�.���'�n��+``�� Orono, MN 55356 <br /> �t���o <br /> Tatal Fo6: `� � �� •��Z <br /> Main: 952-2c19-4600 Fax: 952-249-4fi16 www.ci.orono.mn.us <br /> This applicat�on form must be completed in fufl and a€I required information must be submitYed_ <br /> Incomplete applicatiorts will be returned. (Please printJ <br /> GEN�}2AL 1NFORNlATEON: <br /> Job Site Address: � Y � � C�a �� a n __--�-��,���� <br /> Will this he a ParadE of Horries, Remodefers Showcase Home or other Display Home? Yes No <br /> !f yes,a specla!event pe�m/t Is requlred�vlth Police Depar7ment t�nc!Clty Council approval 60 days prior fo the evenL Shuttle bus service wi!!be <br /> requlred unl�ss ap�llcant clemonsnates scrfflclent on-slte pAiiCing is availab(e. Non-permitiecl events wil!nof be allowed. <br /> GONTRACTOR!APPLICANT INFORMATION: <br /> Name: _�.. .,....�.�.._�.. �5�f 3 y S � L� il 7 <br /> State License# � " THD At-Z-�oY2ie Se�vice, Tne, ,J p d, <br /> Phone: 2690 Cumbe,rland�'�wy, Ste 300 (cell) <br /> Mailing Address: Atlant� CxA 30339-3913 ZIP� <br /> Contact Person� — X,ic#CR2682�7 Ph. 763/542-8826 {omeowner �ci��i�o�e� <br /> Email �nd/or Fax: <br /> PROPERTY OWNE�IPVFaRMATIOfV: � t r � <br /> Name: _ � l'.t�V� _— -�-- -� <br /> Phone(daY): 4 I',t 'S 0 • �tl L J <br /> Address� , �j a ,/� �/` [ ( � Ci � W �' T Qf��i, ZIP_ S 5 <br /> Emai3 and/or�ax <br /> PROJECT INFORMATION: - <br /> j Type of Project: Any earth movement may require I <br /> ' MCWD review 8�permits <br /> ❑ Door{s) ❑ �e�r�ociel ❑Water oamac�e <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair �Stonn Damage 18202 Minnetonl<a Blvd <br /> Deephaven. MN 55391 <br /> Siding ❑ Resforation ❑Other(specify) Phone: 952-471-0590 <br /> FaX: 95'L-471-U682 <br /> ❑ fte-roof �Fire Damage w�nn�v.min��ehahacraek.om <br /> Qv2rall ProjQct DesCription: R y/ . <br /> �stimated Construcfion VaivaEion of Prdject excluding land) $ S/ p 2 � <br /> APPLEGANT ACKNOWLEDGEMENT: <br /> . Agrees to provide ail fnformation required or requEsted bythe 8uifding Qepartme��t; <br /> . Certifias that the irrformation supplied is true and correct tio the best of his/her knowledge. 7he applicant recognizes that they <br /> . are solgly responsible for submiYting a complete applicatian being aware that upon fiailure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> � • SoCr�e or all of trle informafion that you are asked to provide on this applicatioi� is classPfied by Statg law as eiiher orivate or <br /> confideniiai- Private data is informailon wh;ch generally cannot be given to tf�e public but can be given to the subject of the <br /> data. Confidential data is informafion which gei�erafly cannot be givon tp either the pUbliC Or the SubjeCt of tpe dat�. QUr <br /> purpose and intended use of this information is to annually update aur records anc'. records of other governmenCaf agencles , <br /> required b l�w. ff ou refuse to su ! the lnforrrtation,the a lic2tion ma not be issued. <br /> Appficant's Signature: �� Date� S�� � 4 1 5 <br /> � <br /> Last Updated: OS-04�2409 � <br />