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06-11-��9 �:33 PAGE2 <br /> ti <br /> � <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> ...::-• •--• Mailing Addrsss: Permit number; �(. D �7 <br /> % .0 ��' �. PO Box 66 <br /> /O� �Q Crystal Bay, MN 55323-0066 Dats received: �P /� Q <br /> IA8' <br /> `'w'� Received by: <br /> � � ZV ,.?;�, �1 Streef Address: <br /> ,�, . '• G / 2750 Kelley Parkway Plan review fee: <br /> �i.���xa��.;� Orono, MN 55356 <br /> �_-`�" Total Fee: ���� <br /> Maln; 952-249-d600 Fax: 952•249-4616 www.ci.orono.rt�n,us, <br /> This application form must be completed in�full and all required information must be submltted_ <br /> Incomplete applications will be returned. (Pleaso prir�t) <br /> GENERAI. INFORMATION: <br /> Job Site Address: _3 3.�U �v7� S� d L 1=� 5 S 3 S to <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a speciAl event permit is requ��ec1 with Police Depertment arrd City Counc;�approval 6U days pnor to the evenr, Shuttle bus se►vic:�,wu!be <br /> requiled unless App�iGant Aemunstr�tt�s�uHir.ienf on�r;ife p;�rkiny is evailavle. NUr)-po/rnlRcd cvcnts will not be Pllowel�. <br /> CONTRACTOR I PPLICAN FORMATION: <br /> Name: M INNE�v7'►4 —CN'rErW�fiGVY/��- �' ��f E� , <br /> State License# Expiration Date: <br /> Phone: ��._ � 2 office � 71 � ` .� (cell) <br /> Malling Address' C �� City: L ZIP' — ^ <br /> Contact Person: �n Appllcant is+�����ontracto / Homeowner {c��i.o�o► <br /> Email and/or Fax: F1� <br /> PROPER7Y OWNER INFORMATION: <br /> Name: MhiLN� F�.ItLCI�-T'DI�, _ <br /> Phone(day): °9'S1 ' �/ �7 3 - S ?S7 � --�-- �- <br /> Address� 1� '�" _ City��n�„ L�S� ZIP: S S 3S� <br /> Email andlor Fax ���� T,��(,p,� �a� �j•��n� _ <br /> PROJECT INFORMATION; _ <br /> Type of ProJect: � Any earth movement may require <br /> MCWD revlew 8 permlts <br /> ❑Door(s) ❑Remodel ❑Water Damage <br /> Minnehaha Creek Watershed Dislrlcl(MCWD) <br /> ❑Window(s) I J Repalr ❑Storm Damage 18202 Minrtetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Slding ❑ Restoration [�Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0662 <br /> ❑Re-roof ❑Fire Damage www;minnehaF�acreek„_,orA <br /> r , --. ._ . --•-- <br /> Overall Project Description: '�'�a*C � � rz r v �- 3 Te✓i��� �0 x �L' J �O�(3�j�2_d <br /> Estimated Construction Valuatlon of ProJect�excluding la d) $ �v � _ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information reyuired or requested�by the Bullding DepartmAnt; <br /> . Certifies that the information supplied is Irue and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware Ihat upon failure to do so, the staff has no alternative <br /> but to rejecl it until it is complete; <br /> • Some or all of lhe information that you are asked to provide on this applicalion is classified by St�te law as either private or <br /> confidenlial. Private data is Iniormatlon wliich generally cannot be givc�n to �he: public but can be given to the suDject of the <br /> data. Confidential dala is information which generally r,annol be �iven to aithar the public or the subjecl of the data, OIIr <br /> purpose and intended use of this inform�tion is lo annually update our rar.ords and records of other governmental agencles <br /> rAc uired�law: If you refuse to supply the information,the application may rlol be issued. <br /> Applicant's Signature: C�L-�. . � ...���.......-_---, Dale: �`�� /���_ � <br /> 6 <br /> Last Updated. OS-04-2009 I� <br /> � � <br />