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JUL=87-20�1 12:29 From: To: 19522494616 Page:2�2 <br /> City of Orono <br /> 6uilding Permit Appiication for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. � - <br /> O���O PO Box 66 <br /> Cryslal 8ay,MN 55323-0066 Date received: <br /> a � SNset Address: Received by: <br /> � 2750 Kelley Parkway Plan retiew fee: <br /> �t�� � Orono,MN 55356 <br /> Total Fee: ��� � L�s <br /> Mein: 952-248-4600 Fax: 952-249-4616 www.ci-arono.mn_us <br /> This application form rnust be completed in full and all required information must be submitted. <br /> Incomplete applEcations will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Slte Add�ss: ��i P�L�'//'✓ /�/� <br /> Will this be a Parade of Homes�Remade ers Showcase Home o�o e�Display Home? Yes No <br /> Nyes,e specia/event permrY is►equiied with Police Department and City CounCil approval 60 days pnw to the evenL Shuttle Ous s �vfce will be <br /> raqui��l un/ess epplieant demonstrat�s sutScieni on-site parking is aveilab/e_ Non peimitted evenfs w10 nof be allowad. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name, ��✓ <br /> State License t� �� Expiratfon Date: �� /� <br /> Lead CertiFication Number. Expiration Oate: <br /> (for work on homes that were consbucted p�or ro l878 <br /> Phon�: � . � (office) (cell) <br /> Mailing Address: / �/ �j�. City: f�j+ �,/�y�ZIP: <br /> Contact Person: �g,��`yy�. �j,� Applicant is: tractor / Homeowner cci�c�one� <br /> Email and/or Fax: �p/,�• ��-�. �p�! <br /> PROPERTY OWNER INFORMATION: <br /> N�me: J"D� �l�diiP///'CG��L'/ <br /> Phone(day): �G1� . l,(�j�• �(� <br /> Address: ���' L%Ff�JG.1ll/V�� �� C�tY'�/11A�1��L.d�P�I P:�'��� <br /> � <br /> Email and/or Fax <br /> PRO.IECT INFORMATION: <br /> Type of Pro]ect: Any earth movement may requfre <br /> ❑Door(s) ❑Remodel ❑Water Damage MCW�revlew S permlt�: <br /> Minnehaha Creek Watershed Distric!(MCWD) <br /> ❑Window(s) ❑Repair ❑Stortn Damage 1820Z Minnetonka Blvd <br /> ❑Siding ❑Restoration ❑Other.(spedfy) Deephaven,MN 55391 <br /> Phone: 952�71-0590 <br /> Re-roof ❑Fire Damage Fex: 952�71-0682 <br /> www.minnehahacreek_or4 <br /> Overall ProJect Desc�iptlon: — <br /> Estlrx►ated Construction Valuation of Pro'ect excludin land $ <br /> APPLICANT ACKNOWLEDGEMENl': <br /> • Agrees to provlde all infortnation required or requesled by lhe 6uilding Department; <br /> . Certifies Ihal the informaGon supplied is Uue and correct to the best o/hls/her k�owledge. The epplicant recogniaes that they <br /> are solely responsible for submitiing a complete application being aware that upon fallure to do sa, the staff hes no altemative <br /> Dut to reJeci it until It is complete; <br /> . Some or all of the informatfon that you are asked to provide on Ihis applicatlo� Is classlFled by 8tate law a� either private or <br /> oonfldentlal. P�lvate data Is Informatlan whlcfi generally cannot be glven to the publie but can be given to the subJect of the <br /> data. Confidendal data is Informallon which generally canno! be given to eilher Ihe public or Ihe subJect oi the data. Our <br /> purpose and intended use of this irtionnation ia annuelly update our records and records oi other go�emmental agencies <br /> re uirred b law. If ou refuse s 1 the in a' th a lication ma not be issued. <br /> ApplicanYs Signature; Oate; ���� <br />