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i <br /> Fro��'Kuepers Construction �188290383 09130/2009 08:23 #+498 P.001 <br /> � *`» <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: c <br /> .�,0,� PO B�x 66 Pelmit numper: ; ���� J <br /> Q Crystel Bey,MN 55323-0066 pete reCelved. � �� D�• !��' ' <br /> StreetAddress: Recaivetl by. <br /> 2750 Kelley Parkway PI2n reviewfee: <br /> �g��o��� Orono, MN 55356 <br /> �otal Fee• <br /> Main: 952-249-4B00 Fax: 952-249-4616 www.ci.orono.mn.us � ,. � .�' <br /> This appllcation form must be completed in full and alf requlred infoRnation must be submitted. <br /> � Incomplete applications will be returned. (P/ease print) <br /> GE ERAL INFORMATION: <br /> Jo Site Address: �1 � F-G P�r��SS �o`� �� a �G ZA�-c� ✓"►N $S'3� 1 <br /> Will his be a Parade of omes, Remodelers Showcase Home or other Display Home? Yes o <br /> I ,e speGa/avent pem►it ia requlred wllh Pollce Department and C/fy Council approvel 80 days prlarr to the event. Shuk/e bus servioe will be <br /> requ/red un/ess app!lcant demonstrates suff/dent on�lte parkfng is eveilable. Nanperm/tted ev�nta wlll not be allowed. <br /> CO TRACTOR/A PLICANT INF R ATION: <br /> Na . 5 �iw► a�s _ � � s ',�.v�� . <br /> Sta �icense# �S�i Expiration Date: b3 /3 I /�)o <br /> Pho e: �1$- aS- o'�0-7 (office) �1 Y^� 83$-']r�i p (celp <br /> Mail g Address: -d< z�o�d v C I Ci � 13 � � ZIP: (� `��S <br /> Con ct Person: � aw�s Applicant is: onVact / Homeowner �c��ia o�.� <br /> �m I and/or Fax: ' S � �I�'-8Z�- 0 3�'� � <br /> I PRO ERTY OWNER INFORMATION: <br /> N arn�: 3:1 1 G�� l�o Y� 17e lm�l <br /> Phone(day): 5 - �1 1 - � S 1� <br /> Address: �1 �-Q, ��+CSs o; � � �a Ci :y�c. Z�+f�+ Z1P: S S 3�► / <br /> • Em I and/or Fax v� a r+nG�-+ : ,C��^^ ' : ► � � }a ,�o�-. <br /> PR JECT INFORMATION: <br /> Typ of Project: Any earth movement may requiro <br /> MCWD review&permits <br /> ❑D r(s) ❑Remodel ❑Water Damage <br /> Mlnnehaha Creek Wate►shed District(MCWD) <br /> ,� ndow(s) ❑Repair ❑Storm Damage 18202 Mlnnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑3' ing ❑Restoration ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 852-471-0682 <br /> ❑ roof ❑Fire Damage www.minnehahacreek.ora <br /> Ove II Project Descri tion: �v q.�d {� I�ce � w�� 5�S Gw.c1 ca, S K� 1 ' ►.,} <br /> Estf ated Construction Valuation of Pro'ect excludin land $ �g �i8� <br /> APP ICANT ACKNOWLEDGEMEAlT: <br /> • Agrees to provide aN intoRnation required or requested by the Building Department; <br /> • Cert�es that the iriformation supplied is true and correct to the best of his/her knowledge. The applicant recognlzes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alfemative <br /> but t0 reject it until it is complete; <br /> • Some or aIl of the information that you are asked to provide on this application is Gassified by state law as either private or <br /> co�idential. Private data is ir�formation whlch generally cannot be given to the pubfic but can be given to the subjecf of the <br /> data. Confldentiaf data is Information whlch generally cannot be given to either the public or the subject of#he data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmenta1 agencies <br /> re uired b law. If u refuse to su I the information the a lication ma not be issued. <br /> Appll nYs Signature: \�, 1� `� Date: � I�O f�G1 <br /> LBst U ated: 05-042009 <br />