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� Oct, 15, 2009 12; 03PM No. 3852 P, 1 « . � City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) __=--- Mailing Address: Pe�mit number; o��1-G�7/� O.��,�.0 P�Box 66 -•- Crystal Bay, MN 55323-0066 Date received: /d /S b 9 ��r ,, Street Address: Received by; TQ,i�._. �,�, �i` 2750 Kelley Parkway _ �,�gg�o� Orono,MN 55356 =____- To,taf Fee; . ��p, ��p .,� Main, 952-249-4600 Fax: 952-249�616 www.ci.orono.mn.us This application form must be completed in full and all required in� s e su�mi ed �`� Incomplete appllcatlons wlll be returned, (Please print) GENERAL INFORMATION: � Job Site Address: �y�'j� C�,�w�a� � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes � N Kyas,a special event permit is required with Police Depa�tmenf and City Council approva/60 days prior to the evenf. Shuftle bus service will be required unless applicant demonsbates sufficient ornsite pa�lJng is available. Non-permiffed events will nof be allowed. CONTR4ICTOR I APPLICANT INFORMATION: Name: S�;I�a,v'.e,�' �roS State l.ir�ense# ' � ____ Expiration Date: 3�/O � Phone: ' d- �7 - offica cell Melling Address: ! O XS'/ ��.(5 i o✓ �3�uc. .._._ __„ . . Cit : 1,tis . . ZIP:s:53�/3 Contact Person: k3zJ�n �2�.�dh�ck�, Applicant is: Contra ' / Homeowner (Clrcl�On�) Emailand/orFax: ��( 95a-�7�-/�so hr�dhZc��_S_._.__,_____Q✓ (o�o�',,._resrv� PROPERTY OWNER INFORMATtON: Name; a � ; L.S►�d Phone(�aY)� —_`L�S�..._.71= 7�s� Address; 7'-�7o Cn.v w.<t►� Si- City:K�QY 7�.� ZIP: v,$',3 J� Email a�d/or Fax PROJECT INFORMATION: Type of Projec� � Anr eartt�movement may require MCWD revlew S�permlts ❑Door(S) ❑Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) �Windqw(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑Siding ❑ Restoration ❑Other. (specify) Phone: 952�71-0590 Fax: 952�71-0682 ❑Re-ropf ❑Fire Damage www.minnehahacreek.ora Overall Pro'ect Description: �.CP�c;n� w'��do cL S 1 ►ti e.X i5�.--��---_........_�._�.._..._.... 1 _ __ .. � +;►�� o�s�yS _. __ Estlmated Constructlon Valuatlon of ProJ�ct(excfuding land) $ //�D !S,�U � APPLICANT ACKNOWLEDGEMENT; • qgrees to provide all inForcnation required or requested by the Building Department; • Gertifies that the information supplied is true and correct to the bast 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 hut to reject it until it is complete; • $ome or all of the information that you are asked to provide on this application is classified by State law as either private or cpnfidential, 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 date. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies re uired b law. If ou refuse to su I the information.the a lication ma not be issued, Applican�'s Signature: �,,,�,� , ,�1�,.��ia.i" Date; ��'- ��'"O � . _______ Last Updal¢d� 05-04•2009