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Sep, 27. 2010 2 : 04PM No, 6029 P. 1 w . .. City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Pe�mit number: �—da � O4v D,j�jO PO Box 66 Crystal Bay, MN 55323-0066 Date received: � � a St�et Addiess: Rec2ived by: . ' �,�' 2750 Kelley Parkway Pla�revfew fee: ��g�o8�' Orono, MN 55356 �/ Total Fee� yw� ) �+ �� Main: 952-249�600 Fax: 95Z-249�616 www,ci.orono.mn,us / Q This appfication form must be completed in full and all required information must ba submitted, Incornplete applicetions wlll be retumed, (Please pnnt) GENERAL INFORMATION,;.,.. � Job Site Address: � � � �rZ.� � � � 0 2-f- Will this be a Parade of Homes, Remodelers Shvwcase Home or other Display Home? Yes !f yes,a special event permit is required with Police Department and City Council epprova/60 days pnorto ths avenf. Shuttle buS service wlll be required unless appllcent demonstrates sufflcient on-slt�pailcing is availab/a, Non-permi8ed eve�ts wilf not be allowed. CONTRACTOR I APPLICANT INFORMATION: Name� 5 v,r v�a State License# �p�.,3 g�3� q Expiration D�te: p Phone: �'�a-1 - /�O O ��office cell Mailing Address: c�� E 'e ( Cit : o l-(�h S ZIP� S 3 C/ Contact Person: �� ..ic�v„c l�; Applicant is: ontra 1 Homeowner �ctrcle one) Email artd/or Fax; 4j R � ,g�� • ,,� S�h,er�.ec� b c��; � � e „� r ,— PROPEE�TY OWNER�.�I FORMATION: Name; Cp�� .� � m Phone (day): _ �0 1 �.=�� e�.- 5 � o� Address: � o � �= e;�� _ �� (� � /V,.� CitY: � �,..� � ZIP: c�3 c�� Email and/or Fax PROJECT INFORMATION: Type of ProJect: Any earth movement may requlre MCWD review�pertnits ❑Door(s) ❑ Remodel ❑Water Damage �Window(s) ❑ Repair Minnehaha Creek Wstershed District(MCWD) ❑Storm pamage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑Siding ❑ Restoration ❑Other. (specify) Phone� 952-471-0590 ❑Re-roof [� Flre Dama e Fax: 952-j{71-0682 www.min�ehahacreek om Overall ProJect Descriptlon, �. � c�� _��+J�s Estlmated Construction Valuatlon of Project(excluding fand� $ �� °�I � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the infoRnation supplied is true and carrect to the best of his/her knowledge. Tha applieant recognizes that they are solely responsible For submiiting a complete application being aware that upon faiture to do so, the staff has no alternativg but to reject it until it is complete; • Some or all of the information that you are asked to provide on this appfication is classified by State Iaw as eifher private or con�dential. Private data is informafion which generally cannot be glven 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 end records of other governmental agencies re uired b law. If ou refuse to su I the information the a lication ma not be issued, Applicant's Signature: G--�� Date: � M a ( � � � Last Updated: 05-04-2009