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_ , City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) -- --- Mailing Address: Permit number. �Q L ��%%g►�,j��,,� PO Box 66 rf 0 . Q�, Crystal Bay, MN 55323-0066 Date received: / �r,: - a '''�?3�� .:.. a. StreetAddress: Received by: �, % {�`��'•�, G�� 2750 Kelley Parkway Plan review fee: l��ys%�?��4,,*v� Orono, MN 55356 �,..,�sx_,i . --- Total F ��"��f �L-j Main: 952-249-4600 Fax: 952-249-4616 www ci.orono.mn.us / � This application form must be completed in full and all required information must be submitted. Incomple�e applications will be returned. (Please print) GENERAL INFORMATION: /� Job Site Address: � �' l,C� /J j!'� � yty �, �Q �'I'I/V ss3 �j Will this be a Parade of Homes�Remodelers Sho case Home or other Display Idbme? Yes No tf yes,a specia!event permit is required with Police DepaRment and Giry Council approva/60 days pr'�or to the event. Shuttle bus service will be required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be al/owed. CONTRACTOR/APPL CANT INFORMATION: Name: } � LLC, State License# (0 3 g sa� Expiration Date: G3 �3/� �,lj/d Lead Certification Number: Expiration Date: (for work on homes that were consirucied prior fo 1978 Phone: ,3 -. �a -�6 (office) 7G 3�S9v�-' 9 cell) Mailing Address: �js City: J mG f� ZIP: S" Contact Person: �, Applicant is: Contrac o / Homeowner �a��one� Email and/or Fax: , � PROPERTY OWNER INFORMATION: Name: G��SIoI ��i s !!Jf�'r�e, ��I�GP Phone(day): 5'a- - (p�— Address j,� City: � ZIP: s,s3 �i Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ;�Window(s) ❑ Repair ,�Storm Damage 18202 Minnetonka Blvd g � Restoration ❑Other: (specify) Deephaven, MN 55391 ❑Sidin Phone: 952-471-0590 ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 www.minnehahacreek.or Overall Project Description: / / y ,S- Estimated Construction Valuation of Project(excluding land) $ / p APPLICANT ACKNOWLEDGEMENT: Agrees to provide all information required or requested by the Building Department; Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; Some or all of the information that you are asked to provide on this application is Gassified by State law as either private or confidential. Private data is information 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 be 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 and records of other govemmental agencies re uired b law. If ou refuse to su t the information the a lication ma not be issued. ApplicanYs Signature: Date: US ��'��1/ Last Updated: 03-01-2011