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., r City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Malling Address: �,��jr�u�er' �0/�_.�j: � O�,�,�0 PO Box 86 , Crystal Bay, MN 55323-0066 ' Oate�nece�red° �0��-� � � o. SfreetAddress: ��ed b�: � ��' 2750 Kelley ParkwaY plart�evi��;fee:' ee �g� a�� Orona, MN 55356 , 7�fal�'ee: �,� �� Main: 952-249�600 Fax: 952-2a9-�616 www.cl.orono.mn.us This application form must be completed in full and all 1'equired information must be submitted. Incomplete appllcations will be returned, (Please p»nt) GENERAL INFORMATION: S � I ' Job Site Address; Will this be a Parade of Homes, Remodelers Showc e Home or other Dlsplay Home? ❑Yes o K yes,a specia!event permlt Is requi►ed with Police Department end City Council app�oval 60 days prior to the event. ShutNe bus serv'�ca will be requlred unless applicent demonstretes suAlclent on-s�e parking is av�llable. Noq-pem�►itted events wlll not bQ alloWed, CONTRACTOR/APPLICANT INFORMATION: Name: C c� ��L��`'�O� S State License# �b a,(, �� S' Expiration Date: 3—3 - 1�� Lead Certification Number: Expiration Date: (for work on homes that were construcfed prlor t�1978 Phone: '7 6�� s._ g 3 3'3 (ofFice) (cell) Mailing Address: ' � � 5 � City: � ZIP: ?a 3 Contact Person: a�rt,� , Applicant is; ontracto / Homeawner �c��e�e ono� Email and/or F'ax: '�6 3^�1 l � — L�.J b � PROPERTY OWNER IN�ORMqTION: Name; rn Giif`� �p�1of p S� C Phone(daY): ��,— `��/ — D� 7 Address; l�-1 H� G l,e.ri'� �1. C�Y� /�v unc� zIP� ,� S 3d`l Email and/or Fax PROJECT INFORMATION: 7ype of Pro)ect: Any earth movement may requlre ❑Door(s) ❑ Remodel ❑Water Damage MCWD review&permlta: Minnehaha Creek Watershed �istrlct(MCWD) ❑Window(s) (�-Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑ Restoration ❑Other: (specify) Deephaven,MN 55381 Phone: 952�71-0590 �Re-roof ❑ Fire Damage Fax: 952-�471-a682 www.minnehahacreek.org Overall Pro)ect Description: � D �'" 'rfOO Estimated Construction Valuation of ProJect(excluding land) $ � DD�• � APPLICANT ACKNOWI.EDGEMENT: ' • Agrees to prov(de sll information required or requested by the Building Department; • Certifies that the inFormation supplied is true ahd correct to the best of hls/her knowledge, The applicant recognizes that they are solely responsible for submitting a complets application being aware that upon failure to do so,the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidsntial. Private data is informativn 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 publie or the subject of the data. Our purpose and intended use of this infortnation is to annually update our records and records of other govemmental agencies re uired b law. If ou refuse to su I the information,the lication ma not be issued. Applicant's Signature: �� Date: �^ ��1 Last Updated: 03-01-2011 l ' d �1Z6 ' �N S�Ola31X3 O�HSd Wd6ti � 8 IIOZ ' OZ ' u��