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Frorn: 04/30/2010 10:32 #562 P.002/005 <br /> � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: permit number o10/D��Oo?g 3 <br /> g,O,� PO 8oX 66 <br /> Q , 0 Crystal Bay,MN 55323-0066 Date reoeived: `�-.7�D^ /O <br /> �-� � Street Address: Reoeived by_ <br /> ��, - � 2750 Kelley Parkway Plan review fee: <br /> teg�xo�.�n Orono, MN 55356 <br /> roca�Fee: �"g 2.7 2-. t '�y"�''-1'� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn,us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplet _applications will be returned. (Please prin[) <br /> GENERAL INFORMATION: � <br /> Job Site Address: c� �`] �v • <br /> Will this be a Parade of Homes, Remodelers Showcase H m or other Display Home? Yes <br /> If yes,a specia/event permit is iequired with Police Department and Crty Co d epprovel 60 days prior to tho event. ShuH/a bus service I be <br /> requfred unless applicant demonstrates sulficient on-slte pericing is evaileb/e. Non-permitted events will not be ellowed. <br /> CONTRACTOR/AQPUCANTINFORMA <br /> Name: /,�t'� � _�� . <br /> State License# Expiration Date: 3-3 1 -/�.Z <br /> Phone: - '8� - � office cell <br /> Mailing Address: � � Ci nr.� ZIP:' <br /> Contact Person: ' Applicant is: n rac o / Homeowner (Clrcle Ons) <br /> Email and/or ax: a_ 8/- <br /> PROPERTY OWNER I FORMATIO . <br /> Name: <br /> Phone (day): b _ � S� <br /> Address: .5,� � � Ci ' /�t�� ZIP: S3`� 9 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel MCWO review 8�parmits <br /> ❑Water Damage <br /> Window s Minnehaha Creek Watershed District(MCWD) <br /> ❑ ( ) ❑ 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 /> e-roof ❑ Fire Damege www.minnehahacreek.orq <br /> Overall Pro ect Descri tion: u�.- Q.0 re�-a-oF ' ; __s <br /> Estimated Construction Valuation of Pro ect excludin land $ � $ .c ,3/ . �- <br /> APPUCANT 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 reoognizes that they <br /> are solely responsible for submitting a complete application being aware that upon faflure to do so, the staff has no alternetive <br /> but to reject it until it Is complete; <br /> • Some or all of the iniormation that you are asked to provide on this application is classified by State law as either private or <br /> confidential_ Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidentia! data is information which generally cannot be glven to either the publiC or the subject of the data. Our <br /> purpOse and intended use of this Information is to annually update our records and records of other governmental agancies <br /> re uired b law. If ou refuse to su I the' ation the a lication ma not be issued. <br /> ApplicanYs Signature: ' Date: �''� �— �� <br /> Last Updated: 0�✓04-2009 • <br />