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SEP/01/2015/TUE �10. 09 PM Elder Jones Building FAX No, 952 8�4 4909 P. 002
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<br /> ' City of Orono
<br /> B�ilding Permit Applic��ion for Internal Work
<br /> (wi��dows, doars, siding, re-roof, etc.)
<br /> --� ivl2ilrngAddres5: Permit number: �=!� ��i ' ( �j���
<br /> -�,�,�:' , PO Box 66 �� , ,t:.
<br /> ' �', a GryStal Bay, V]N 55323-0066 Date r�ceived= _
<br /> �� <,;:
<br /> -�+�� Recei�ed by: 1�
<br /> I ; F;��';ri',;:,.,':., a� Street Address:
<br /> ``'S' �"�'-•;I��'?�"V ti/ 2750 Kelley Parkway , Pl�n revi�w fee: \
<br /> tn %�E?r1„ ,�,. ,Y:� c,
<br /> �' � i�:V������� � Or•ono, MN 65356 � � �
<br /> ;`�rr�si�ot`
<br /> I rpt�� Fe2: � ,:. 4G� . 1-�,
<br /> V A�ain: 95`'-249-4u"00 Fax: 952-249�4G16 wv�w.ci.orono.n�n.us
<br /> 1 This application fiorm must be completed in fiul[ and ali required i��formation musi be submitted.
<br /> Incomplete applications will be returned. (P/ease prir;f)
<br /> G�N�RAL INFORIV�ATIDN: /`
<br /> ,3ob Site Address_ ' � �' � q, (�
<br /> �.Nili this be a Parad� of!-lo���es, RemocJelers Showca5e I-iome or other Displ�y Home? [{ Yes ❑ No
<br /> If yes,a spacia!�venl ermil is rc�quired with Police Depar!mertf and Cify Council�pprovel 60 dz?ys/?riol'to fhe ev�nx, $hutt,'e bus s3n�it�wN!be
<br /> r'oqwir'ad u�less appl;car7t dsmon�trvfas suff;ciant cn-siis pa�krng(s avallabls. Non-permiftad evPnts will not be allowod.
<br /> CON7'FZACTOR/APRLiCAN7' INFQRMATION:
<br /> Name: �I `�S� ��►S• 6 e y�'
<br /> 5'tate License� � - r pella Northland
<br /> Phone: 15300 25t1�Ave N. Ste 100 '(ce!I)
<br /> �,4ailing Address� ��y1Tlouth, MN 55447 ZfP� _
<br /> Contact Person: Lic#�3C6�5090 ph. 763/745-1400 {ameowner �Gircle one)
<br /> Email and/or i=ax:
<br /> F'R�PERTY OWNERIINF RMATION: ,
<br /> '�ame� �..�G /' Q• -w
<br /> Pho��e (day}: µ.L.,,�� ,� . Q �( � F l
<br /> .4ddre55: � 1' Clty' W Q y Z'a T'a, ZIP: 5 J�_3�1
<br /> Email ar,d/or Fax ' ' ,M�,
<br /> Pi�OJECT INFORMATION�w� �
<br /> ; Type of Project: ' Any earth movem�nt rnay require
<br /> _ MCWD revie�w&permits
<br /> Coo�(s) � ❑ Remodel ❑:Water Damag�, �',�'- - -
<br /> • Ninnehaha Cre�k Watershec OistriGt(MCWD)
<br /> ❑Window(s) � ❑ Repaia- � Storm Damage ` 18202 Minnefonka Blvd
<br /> Deephaven, MN 55391
<br /> ❑Siding ❑ Reetoration ; ❑ Other. (specify) - Phone: 952-471-0590
<br /> ; F8X' 952-47'f-0682
<br /> Q ��-roof ' '� Fire Oamage � vvww.rninnehahacreP�„k.orq _�
<br /> Overalt Project �esc�ipEion: � � p C,L I A. ��s�� �n���
<br /> �stimated Construct on Vafuation of Project(excluding land) $ �y y j`p
<br /> APPLICANT ACKN WLEDG�M�NT:
<br /> , • Agrees io provicle all infora-�ation required or requested by the Building Dgp�rtmoizt; � �
<br /> • Cei7ifies that tn� informztion supplied is true and correct to the be5t of h�S/h�r knowledge. The applicant reCognizes tha[they
<br /> are solely respo�sible for submitting a complete appfication heing aware that upon failure to do so, the StBrr has no altemztive
<br /> ii�u:to rEjeot it u til it is complete;
<br /> . Spme or al! pf th4e information that yau are asked to provide on this application is classified by State law as either private or
<br /> confidenfial. Pri ate data is infcrmation which generally cannot be given to the public but can be given t0 the SUbj9Ct of the
<br /> � data. Conf�den��a! data �s informatior which c�er:eralfy cannot ba given #o either the public or the subject of the data. Our
<br /> � purpos� and int nded use of fhis information is to annually update our records and records of other governmentcl aqencies
<br /> j_ re uired b 'raw. 'If ou refuse to su ol the information,the a IiC21i0n R12 not be issued. �� �
<br /> �
<br /> Ap�licant's Signatur�: ', ��"" pafe� ��3 6 l! �
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<br /> Last Updated: 05-D4-2009
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