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JUN-09-2011 03 :21 PM WALKER, ROOFING 6512510916 P. 01 <br /> � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> �windows, doors� sidln � re-roof, etc.) <br /> Melling Addrgss; /�,� (� <br /> ,,;;���-�^-'-�� Permit number; <br /> ��I„Q,�, PO Box 86 <br /> �O \ Crystal Bey, MN 55323-0�96 Dete recelved: <br /> �� ��� <br /> � � , � ��.'�_„ �/' Street Address; Received by: <br /> � � �' 2750 Kalley Parkw�y Plan review fee� <br /> i,a�, , �j Orono, MN 55356 � . 2 <br /> �" �-��� Total Fee: �j��• J� <br /> Mein; 852-248�600 Fax: 852-249-4918 www.ci,orona.mn.us <br /> Thi��pplic�tion form must be completed In lull and all required Informatlon must be submitted. <br /> Incomplete appllcatlons wlll be returned, (Please print) <br /> OENERAL INFORMATION• .� C � ��D ,�,� <br /> Job 8ite Address: <br /> WIII thle be a Perade of Homes, Remodelers Showcase Home or other Dlsplay Home? Yea No <br /> K ypa,a speclal event pe�mlt Is required wlth Polke Depertment end Clty Council epprovel 60 days prior fo!he evenk Shuttle bus ssrulee wlll bo <br /> �equlied unlees appNcent demonsb�tes suh'Icfent on•site p�rkinp ia eveileble. Non-permitted evants wlll not be allowed. <br /> CON7RACTOR/APPLICANT INFORMATION: <br /> Neme' p� ►� <br /> State Licen�e# fH�,,2� Explratlon Date; � <br /> Lead Certificetion Number� �'— ��q�� (o _ Q�� � Explratlon Date: � � <br /> (for work on homsa that►ewro conatructod prlor t� 1878 <br /> Phone: .��9� (office) (cell) <br /> Mailing Addregs; 1�{ p� City, („ ZIP; ( <br /> Contact Peraon; � Applicant is; actn I Homeowner �ci.��.o�el <br /> �mail andlor Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name; �.0�11 E i1et�� �`I �C-C.. <br /> Phone(day); r7 6 3— G _��•�L 1 <br /> Address, �-� $ .f��/C. r„tm�0 City: ����,yq,j^/ ZIP� T., s''�Sq <br /> Emall and/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJeat: �ny sarth movement may roqul�e <br /> ❑ Door(s) ❑ Remodel ❑Water Demege N�CWD revlew d permlta: <br /> Minnehaha Creek Watershed Qistrict(MCWD) <br /> ❑Window(s) �Repelr ❑ Storm Dam�ge 18202 Mlnnetonke Blvd <br /> ❑ Slding ❑ Rostoratlon ❑ Other: (apecify) phoneeV952-471 0 001 <br /> �.8e�roof ❑ Flre Demage Fex: 852-471-0682 <br /> www,minnehahacreek.ora <br /> Ov�r�ll ProJect D�acrlptlon: � ��. <br /> Estimated Construction Valuatlon of ProJect(excludlnp land) $ 7 ►,����$ <br /> APPLICANT ACKNOWLEDOEMENT; <br /> • Agrees to provide all informatlon required or requested by the Bullding Depertment; <br /> . Certl(lea th�t the Intormetion eupplied is true end correct to the beat ot hla/her knowledge. The applicant recognizes that they <br /> are solely responsible for aubmitting a complete appllcation being awa�e that upon feilure to do so, the etaff hes no elternative <br /> but to reJect It untll It I�complete; <br /> • Some or all of the informatlon that you are eaked to provlde on thls applicetlon le clesalfled by Stete lew es elther private or <br /> confldentlal, Prlvete date is informetion whlch general�y cennot be glven to the public but can be given to the subject of the <br /> data. Confldentlal dete le informatlon whlch oenerelly cannot be given to either the public or the subject of the data. Our <br /> purposa and intended use of this infprmation ie to ennuelly updete our recardo and recorde o( other governmentel egenciea <br /> re uired b law. 14 ou reFuse t su th ' formetion the� lication ma not be issued. <br /> Applicant's Signature: - Date; <br /> l.det Updflted: 03-01-2011 <br />