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' , �� RE�`EIVED <br /> . � City of Orono <br /> Building Permit Application for Internal W rJ'kN 25 2010 <br /> (windows, doors, siding, re-roof, etc.) ����FORo <br /> Mailing Address: Permit number: al'/D ^�� <br /> O�,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: / 1.0�0 <br /> ��;� � <br /> a ,:z� a, Street Address: Received by: <br /> '�'.�c, �` �ti 2750 Kelley Parkway Plan review fe� <br /> t`��Esxoi''� Orono, MN 55356 <br /> _= Total Fee: � ��� � �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci crono mn us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: Z`63S LCL`�� �r. �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> lf yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: c1c � 1��.�� �l E�. tN <br /> Phone (day): �SZ.,dFl i.. ����7Ch,� �f Z - C'�- 71� c v <br /> Address 2f'���5 � C�j�� �� tY� L� IZ�1T�r ZIP: ��r>�l 1 <br /> � `�'"� (:.,i� Ci V <br /> Email and/or Fax _-�i�J�-��i 2�� (�� cZc I .Ln�Vl . <br /> .� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD�eview 8 permits <br /> �Door(s) (�'kemodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> 0'Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑Restoration ❑ Other: (specify) Phone: 952�71-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage_ www.minnehahacreek.orQ <br /> Overall Project Description: )N�� �+���� �- �JA i C ' t �T�N�IV 'UA'� N�.' W ��+v DD �`= <br /> Estimated Construction Valuation of Project(excluding land) $ �Fj'c`� C'�C��`� < c+e, <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> J , <br /> ApplicanYs Signature: %r~,,�1,��-'�2�_GL�2.� c�-{-� �-�`-- Date: ��G�-� ����C"j <br /> Last Updated: 05-04-2009 ` <br />