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r • Sep� �T• �OI � / � LJI`11t1 IYQ� VOIV 1 � � City of Orono Building Permit Application for in#ernal Work (windows, doors, siding, re-roof, etc.) Mailing Address: ��//_0/Q Jr.'� Og�j�O PO Box 66 Permit number: _; Crystal Bay, MN 55323-ooss Date received: ~ �� .� �� a, St�eet Add�ss: Received by: �, �� `� � 2750 Kelley Parkway Plan review fee; �k�sxo¢$ Orono,MN 55356 c� �- —�—` Totaf Fee; � o�a� � / Main; 952-249�600 Fax; 952-249�616 www.ci.orono.mn.us This application form must be completed in full and all�required information must be submitted. Incomplete applications wlll be returnad, (Please print) GENERAL INFORMATION: Job Site Address: � 3.S �e,v y cQ�.r�,__ pcz,�� Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? ❑ Yes [] No ff yea,a specia!event permit is roqulied with Police Dapartmen!and City Council epprova160 days prior to the event. Shuttle bus service will be required unless appllcant demonstrates sufficient on-site parking is available, Nonpermitted events will not be allowed. CONTRACTOR/APPLICAN7 INFORMATION: ►vame: 5cr��.� ;r�5 State License# �o,�3`i3� 5' __„__ Expiration Date: � 3 Phone: �`5 a-1 7 7— (�_O U offce ce{I Mailing Address: n y � ��, C' : o ,lti�h S ZIP� 5;5'3 S�� Contact Person: _ ,� Applicant is: ontrac o I Homeowner �ci��i.o�.� Email andlor Fax: PROPERIY OWNER I��i1 FORMATION: Name: ft:-, �eR � \-. �. Phone(day)� '� � �� Add�es5: , 1 3S c_.h� a � cD;�.�, - CitY ��r' � ZIP: S S39� Email and/or Fax PROJECT INFORMATION; Type of PmJect: � �� Any earth movemerit may require MCWD review 8�pertnita ❑Door(s) ❑ Remodel ❑Water Damage Minneheha Creek Watershed District(MCWD) '�Yndow(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Siding ❑Restoration Deephaven, MN 55391 ❑Other.(specify) Phone: 952-471-0590 Fax: 952�71-0682 ❑Re-roof ❑Fi�e Damage www,minnehahacreekom .. ......__: ...................__.. _.:_........ Overall Project Description: vEstlmated Constructlon Valuation of Project(excluding land) $ � �rf� , � � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all infomtation required or requested by che Buifding Department; • Certifies that the information supplied is true and correct to the best of his/her knowfedge. The applicant recognizes that chey are solely responsible for submitling a complete 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 appllcation is classlfied by State law as either private or confidential. Private data is informaGon 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 he given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records end records of other govemmental agencies re uired b faw. If ou refuse to su I the information the a lication may not be issued, ApplicanYs Signature: �-`�� "'�c_ ... .._.__ .. Date: �'�� ^� � Last Updated� 05-0420o9