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� p` I � �\ <br /> . � .� � ��.�-( <br /> City of Orono �" <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �--�� MarlingAddress: Permitnumber: db�0- VO7' <br /> ��,0,�.� PO Box 66 <br /> ��O :\ 0\ Crystal Bay, MN 55323-0066 Date received: /O <br /> � �' ��� �i Received b <br /> ,� ,���z�-` s,�� Street Address: Y <br /> �'.�e, 3i�,�� •� �ti ' 2750 Kelley Parkway Plan reviewfee: <br /> l9kEs��4w Orono, MN 55356 /� � � <br /> Total Fee: .(y � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �] <br /> This ap�lication form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: +�j�5 �o �1 COrC�,�c� 5`1- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> !f y2s, a specia!even!permit is required with Police Department snd City Council approval 60 days pnor to the event. S.huttle bus�ervice will 6e <br /> required un/ess app/icant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> N a m e: J c,i�:�.-�'�-v' �`3•a�:; <br /> State License# �2cr;i ,3 �3 C�, � Expiration Date: 3�j� <br /> Phone: �'S�-� 7 7- /� C� C� office cell <br /> Mailing Address: Jc;;i��� c C ^ ;�v ��1 uc� City: �,L�GI'�v�S ZIP: .,���'3 �!-3 <br /> Contact Person: �i..,4-�-� ..zc�„��c k� Applicant is: ontrac o . / Homeowner �Clrcle One) <br /> Email and/or�x:� `i,S•� - � 7 7—/� �'l v <br /> PROPERTY OWNER INFORMAT N: <br /> Name: j�iCl-C a. 4`�Z <br /> Phone (day): �j;��- 71 " �0•5-� <br /> � Address: J�j Y S- C���c��-r�i�:.�-� S 1' City:�Vc v�o ZIP: ��S 3`/ � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> ' Type of Project: Any earth movement may require <br /> MCWD review 8�permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> I�Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: � I�c'c r ' I w`� ���c�:, : k ex'�S�✓� ' c� �-���✓� `7 <br /> Estimated Construction Valuation of Project(excluding land) $ � �,5-0��} <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 classifed by State law as either private or <br /> confldential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confdential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpo�� 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 /> ApplicanYs Signature: ����.�,,.�,���' Date: � ��--`�/(� <br /> Last Updated: 05-04-2009 <br />