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, JAN�0-20�1 01:49 FROM:TREBILFOUNDATION SYS 3205938720 T0:1952 49 P.2�3 <br /> � <br /> � City of Orono <br /> � <br /> Building Permit Application for Int rnal Vy , <br /> (windows, doors, siding, re-roof, etc `' <br /> �- �� Mailing Address: � ����_� �' <br /> �,L�,;� PO Box 66 �� <br /> 0 � �0 Crystal Bay, MN 55323-0088 Qate receivad: � /a / . <br /> � �� � Street Address: R6ceived by;, <br /> E. �,�' 2750 Kelley Parkway Pla,n review fee: <br /> ��tly/ � Orono, MN 55356 <br /> Total Fee: <br /> Main: 852-249-4600 Fax: 952-2a8-�616 www.ci,orono.mn,us <br /> This application form muat be completed in full and all required information must be submitted. <br /> Incomplete applicatlons wfll be retu�ned, (Pl�ase print) <br /> GENERAL INFORMATION: <br /> Job ite Address: <br /> Will t�iis beia Parade of Homes, Re a lers Showcase Home or ather Display Mome? Yes o <br /> II ,e Sppcl8l event perrnit!s�eq�red with Police Department and Clty Councll approval BO deys prior to the ewent. Shuttle bu8 seNlCe ll be <br /> �roqulrod unless epplice t demanstiatss suN/clent on-sire parking is available. Non-permitfed evenrs will not be 9/lowod. <br /> CON RACTOR/APPUCANT INFORMATION: <br /> Nam • �r��`T_��o� \ ��rcL�:c.,-. Sw�� A.,r.� nr� <br /> Stat Licen�e# _����y go, Expiration Date: 3_��.a.��J7� <br /> Pho e: �-��_�-�"1�� (office) (cell) <br /> Mailirg Address: (��� � .�,\�;��,\c„ `-Z,,,, CItY: �l.S�l� ZIP� y��'3 �` <br /> Cont�ct Person; ��.,s�, (�,r�,,: ��� <br /> Emai and/or Fex: �Z��_ ��.�;3_.���°'�"�����pplicant is: Homeown�r ici.�ioo�.� <br /> � '—' <br /> PROPERTY OWN� INFpRMATION: <br /> Nam�� ��.�� ���,,� r c�0.r c\. <br /> Phone (day): � �' � <br /> Address: Cit : c�..,�G 21P�� � <br /> Email and/or Fax Pw . � C� <br /> PROJECT INFORMATION: <br /> 7ype of Project: Any earth movement may requlre <br /> MCWD rovlew 8�po�mlts <br /> ❑ Door(s) ❑ Remodel ❑Wacer Demage <br /> ❑Window(s)I �Repair Minnehaha Creek Watershed District(MCWp) <br /> ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑ Restoration � Deephgven, MN 55391 <br /> � �Other: (specily) Phone: 952-471-0690 <br />� Fax: 852-471-OG82 <br /> [�Re-roof (] Fire Damage �e����, c���e, <br /> - www.minnAhahaoreek.ol� <br /> Overall Project Descrlption: � ' � � <br /> Estimated onstructlon Valuetion of Proje�ct(axcludin nd) $ � � <br /> APPLICANT ACKNOWLEDGEMENT: I <br /> • Agreas to provide all information raquired or requested by the Building Depar7nent; <br /> � C�rti6es thet the informatian supplied fs t�ue and correct to the best of his/her knowledpe. The applicant recognlzes that they <br /> are solely responsible for submitting a complete applic�tion being aware that upon failure to do 80, tha st�ff has no alternetive <br /> but to rejoct it until it i�complete; <br /> • Some or all of the information that you are Aoked to provide on this applicCtion i;, clas3ifiod by State law ae either privete or <br /> confidentiel. Privete data is information which generally cannot be given to the public but can be given to the subject of the <br /> dats. Confidential data is information which generally cannot be given to either the public or the subJect pf the data. Our <br /> purpose and intended use of this information is to �nnually update our records and recofds of other governmental agencies <br /> re ulred b law. If ou refuse to su I the information the a lication ma not be issued. <br /> Appli ant's ign�ture: - , - — Date: <br /> �����o� ��, �O\\ <br /> Lasl pdated: 05-Oa2008 <br /> � <br /> 1 <br />