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�� <br /> 2011-06-07 07;38 DYUIG 9529388792 » +9522494616 f P 112 <br /> , � City of Orono <br /> Building Permit Application for Internal Work � <br /> (windows� doors� siding, re-roof, etc.� <br /> Meiling Address� Permil numbe�: O//-b6 cj <br /> .¢�,� PO Box 66 <br /> � Q Crystal Bay, MN 5532�0066 Date�eceived: / <br /> a � srreef add�ess: Rec�ired by: <br /> 3�, 2750 Keller Psrkwsy Plen review fee: <br /> ��� Orono,MN 553b6 <br /> -- Totel F@�: <br /> Mein, 952-24S�G00 Fax: 952-249-4816 www,ci,oro�o.mn.us <br /> This applicabon inrtn must be complete4 in full�nd all required information must be submitted, <br /> Incomplote appllcatlons wlll be retumed. (Please prin�) <br /> GENERAL INFORMA710N; Q I J �/�/�� I��S O J�� n/1� ��n� �'rj� s�3� � <br /> Job 8fte Addnss: 0 /`� V �V <br /> WIII this be a Pw�de of Homas,Remodvlers Showcase Home or other Dlap ay Home? Yes No <br /> If yw,e spectiel erent pBmtlt!s/eqvired wrM Polbe Depe/hnenf end CNy Council epprvvel BO deys prior to the evenL Shuttllie bus will be <br /> requlred unkss epplfaent demonsbstea auJflclent on-sl(�parklnp!s evolleble. Non permltted events wIN not De allowad, <br /> CONTRACTOR I APPLICANT INFORMATION: � <br /> Name: MA�' L • � <br /> State Licenae# pb � o Expiration Dete: 3 ' I ' 0 3 <br /> Lead Certification Number; N l�- ���r 19�i Expiration Date: /V <br /> (foi►+rork on hamas ti+at wwo wcted prlor(p 1978 <br /> Phone: � - S�-- (ottice) s� � �'��`� (celq ��ySL <br /> Mailing Address: �k� - � �. City: '��Q Gy� ZIP: j $� �1 <br /> Confact Person: -�orn�S �Yd�Sr Applicant is: ontrac / Homeowner (CIrcNOn�) <br /> Emall and/or Fax: p��� �q ��e o p mQ� tr �� � <br /> PROPERTY OWN�R INFORMATION: n�r� �L S��n„L�S y LA� <br /> Name: �y <br /> Phone(day): � _ ( � <br /> Addr�ss: �5 '/� L/1eSS c�cy: 02dhD Z�P: J s3 <br /> Email andlor Fax �n A • (' � <br /> PROJECT INFORMATION: <br /> T�rpe of ProJect Any oortt�movomeM may requlre <br /> Q Door(s) []Remodel []Water Damaye MCWD review 8 permib: <br /> Minneheha Creek Wetershed Dfatrfci(MCWD) <br /> ❑wndow(s) []Repeir ❑Storm Damafle 18202 Minnetonka Blvd <br /> ❑Slding ❑Restoration �Other: (speciy) Deephaven,MN 55391 <br /> Phone; 852�71-0590 <br /> ❑Re-roof ❑ Fire Damage E� � Fex: 952-471-0682 <br /> (S�, A�'Ik www.minnehahec►aeK,OrQ <br /> Overall Pro eet DescMptlon: x p� rn� . 5� on� IOX�M d o �ci � �' ` ��,� <br /> EstlmAted Constructlon Veluatlon of Pro ect excludln land) s ..d n �� <br /> APPLICANT ACKNOWLEDQEMENT: <br /> . Agrees to provide all Intortnetlon required or requested by the Building Depertmenl; <br /> • Ce�tifies that the information aupplied is true and correct lo the best a�hls/�'�er knowledge. The�pplicant recognizes that lh@y <br /> �re solely�esperosible (or submittting e compkte applicatlon being eware tha!upon failute lo do so,the ataff has no eltemallve <br /> but to reJeCi it until it ia complete; <br /> • Some or all ot the infortnetion that you are asked to provide on this spplicetivn Is claesified by Stete lew �a elther ptivate or <br /> confide�tiaL Privete dals Is informaUon which generally cannot be given to the public but cen be glven to tl�e aub�ect of the <br /> dats. ConfldenUal dsta is information which generelly cannot be given to either the public or the Bubject of the dals. Our <br /> purpose and intended use of thia informetion la to ennuelly update ou�records and �ecords a�F other governmentel agencies <br /> r uired b lew, li ou refuee to�u I 1he informetion 1ho e liceliom m �v1 bo iaaued. <br /> Applicant's Signature: � D�te: S �d� <br /> n„� � �.._,� .. ,..��.. , , � <br />