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Se;� 1,5. 10 01:29p TIMBERLINE ROOFING & SIDI 952-926-1368 p.1 <br /> City of Orono <br /> Building Permit Application fo� Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Marling Address: Permit nurnber: o24/D— (•10��� <br /> � PO Box 66 <br /> ��� �O:\� Crystal Bay,MN 55323-0066 Date received: 9- �S- /D <br /> ,�„� ��� ��•-� ,,�l Street Address: Received by: <br /> "��� �'�� Planreviewfee: <br /> `•'��, , � Gti� 2750 Kelley Parkway <br /> �l � Orono, MN 55356 <br /> �xO4 <br /> Total Fee: �7D '"j0 <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 /> Incomplete applications will be returned. P/ease print) <br /> GENERAL INFORMATION: c,i -- p / � <br /> .lob Site Address: 1 �d�G�G'G2 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> liyes, a specia!event permit is required with PoJice Departmer,t and City Council approval 60 days pnor to the event. Shu7/e bus service wil�be <br /> r�quired unJess applicant demonstrates sufficient on-site parking is available. Non-pe�mitfed events will not be allowed. <br /> CONTRACTOR I APPLICA T INF RMATI . ' <br /> Name: —%�`+ i�w_ f ,s���•^ � <br /> State License# Z('� Z Expiration Date: - - <br /> Phone: — 9Z — 9 office ( �(n cell <br /> Mailing Address_ o "/ G, .f`✓r Z7d Ci : MALS ZlP: ' <br /> Contact Person: � � �y. Applicant is: nt act / Homeowner (Cirnle One) <br /> Email and/or Fax: �/Sy � "LG � � _ <br /> PROPERTY OWNER INFORMATION: <br /> Name: i� r��v� <br /> PF�one(day): �S�L - `�?(. • "7 O ��9 <br /> Address: �y��� Ci :C�I'�uo f� �CZ1P_ � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑Doo�(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑wndow(s) ❑ Repair ❑Storm Damage 18202 Minnetanka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding ❑ Restoration ❑01her: (specity) Phone: 952-471-059Q <br /> � Fax; 952�71-0682 <br /> e-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Descri�tion: <br /> Estimated Constrvction Vatuatian of Project(excluding land) $ ` li�. <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Departmenl; <br /> • Certifies that ths information supplied is true and correct to the best of his/her knowledge. The applicant recogniz�s thai they <br /> are solely responsible for submitiing a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it untii it is complete; <br /> • Some or all of the information that you are asked to r�vide on this application is classified by State law as either private or <br /> confident�al. Private data is information whieh er ly cannot be given to the public but can be given lo the subject of the <br /> data. Confidentia( data is information whic en II cannot be,given to either the public or the subject of the data. Our <br /> purpose and intended use o(this inform ' i o a ally update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su e i rm n,1he a lication ma notbe issued. <br /> . � _ <br /> i / <br /> ApplicanYs Signature: � Date: r r '�! �O <br /> � <br /> Last Upda[ed: 05-04-2009 ✓ <br />