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BANNOCHIE BUILDERS 76�5740131 02/13109 08:36pm P. 002 � City of Orono Building Perrnit Application Mailing Address: Permit number: `� '. -�' � ' h. �Q, PO Box 66 ��r. �� Crystal Bay, MN 55323-0066 Date Teceived: " c�C�C� O �\,, � . 1 �, �',� ��` ��,�- ,,�i StreetAddress: Received by: d� �. �i�" ti�/ 2750 Kelley Parkway Plan review fee: ' � � 1� ` '� �� �t ` w° Orono, MN 55356 �I�1 � � r r I � '9k'�sfsoi/ - , —. Total Fee: �7 �= r ; �� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � i; % This application form must be completed in full and all required information must be submitted. Incomplete appiications will be�eturned. (Please print) GENERAL tNFORMATION: � Job Site Address: � �� a°�''`�"�a�ll��' �T '� C�r,.�C..� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No. If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates suffrcienf on-site parking is available. Non-permitted evenis will not be allowed_ CONTRACTOR/A/PePLICANT INFORMATION: „�.7 ` . Name: Var�..q �n�.nr. �i" m '�" v�� `;'1.i.�= �v� ��;Er�<� �,r�c' ..... State License# �G�� '�f i'��3 , � Expiration Date: `3 "�f.� %l��`'1 Phone: `�+�a"3 F S, � ,� lJ f'�:3 / (office) �f'j� >,�oi v� ��5�%' (cell) Mailing Address: Q[S t�� o�2c�'-� 3 Gity� �,r` L�=� ZIP: �'S�%��? _ _ Contact Person: T �bn'�f�d`'�f'�r1 w*C{,��--�- Applicant is: Cof�aCtOf / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNE,�5 INFORMATION: Name: �" � � �t" e.�.,,�. , ,�,. Y�. �. Phone (day): �5��?,. t� 7� G� _ , ,u � � Address: ';��c{l�+ L`t�-�'�n� � Citr��. (,�f`��i C.� ZIP: 5� ,�„� �a Email and/or Fax PROJECT INFORMATION: . Type of Project: Any earth movement may requi�e n Q� h D �� MCWD review 8�permits ❑ Door(s) �Re �`j �V � linnehaha Creek Watershed Distcict(MCWD) ❑Window(s) ❑ Re� CQ�� Z��7 18202 Minnetonka Blvd i Deephaven,MN 55391 i ❑ Siding ❑ Res �y� Phone: 952-471-0590 � {� � " Fax: 952-471-0682 ❑ Re-roof ❑ Fire �( �� be , www.minnehahacreek,ora Estimated Construction Valu �� G.J�ANNoGN/L �°a APPL.ICANT 8� OWNER ACI � /� � • Agrees to provide all inforn �� nt, � • Certify that the information � wledge. The applicant and owner recognize � that they are solely respc 'IZ�f�� 9 aware Yhat upon failure to do so, the staff ; has no 2�Iternative but to i �� I . The Owner hereby acknow �orizes reasonable entry onto the propeRy by ; City Staff,consultants or ag _�_...,,. ! • Some or all of the information tnat you are asked to provide pn this application is cfassified by State law as either private or I confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the � data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our , purpose and intended use of this information is to annua►ly update our records and records of other governmental agencies i re uired b law. If ou refuse to su 1 the informatfo , the a lication ma ot be issued. � . - ._.... ,, ' /:. �l � � / � �� / ApplicanYs Signature: � '� .� �►�-�-��z� " Date: , i E�� , Owner's Signature- Date: