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o���z�zo�o �o� �� z� ��x �ooz�ooa <br /> � <br /> City of Orono <br /> 6uilding Permit Application for tnternal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> A�4ailing Address: Permi[numDer: o�0/O— <br /> O:g,�„j�.O Pp 6ox 66 <br /> p <br /> Crystal Bay. MN 55323-0066 Date recelved: 7l/ /� <br /> ���� a, 5treet Add�ess: Received by: <br /> � � � � �� 2750 Kelley Parkway PI2n f2Vf@wt@@: <br /> ���,xz�o��. Orona,MN 55356 ���� � <br /> -__= Totsl Fee: <br /> Maln: 95Z-Z49•4600 Fax: 952-249-46'16 www.ci.oro�o.mn.us <br /> , This application Form must be completed in full and all required information must be submitted. <br /> ' Incomplete applications will be retu�ned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 1� �o r���,v G✓�� ;,..� <br /> Will this be a Parade of Homes. Remodelers Showcase Home o�other Display Home? Yes No <br /> lfyes.a speclal evenl permlt!s requlreo w�ln Pollce Depar(men�and G!ry Caunc!!approva!BO days prlor b the event. Shuftle bus servi�e wil!be <br /> ioquiipd un/ur�appl;eanl dpmon�fra(ag Fu1/icionl on�i�a parkfng;s avallaula. Non.paimltrad evenfs will nof be slloweA. <br /> CONTRACTOF2/APPLICANT INFORMATION: <br /> � <br /> Name: '� G.� <br /> State License# %7 �L Expiration Date: �i"5 3/ /zoi Z <br /> Phane: •� •- �" � --/3 ���� office cell <br /> Mailing Addre��: ��F'`+ Cit : ' / .a.-, � IP: S-4+z. ' <br /> Cont�ct Person: ' �„ O Applicant is: ontractor / Ho owner (Circic On4� <br /> Email and/or Fax: �G� �; �/ .�., G� �-e� <br /> PROPERTY OWNER INFORMATION� <br /> Name: �o�h �� fo��i ,��. <br /> Phone(day): L — `f a — /.6 <br /> Address � � v i� • � ,- � ,?��� v-Z Citv: ��'�y=� ZIP: ��S'3�/ <br /> Email and/or Fax <br /> PROJEGT INFpRMAT10N� <br /> Type of Proiec[: Any earth movement may�equire <br /> MCWD rovicw�permits <br /> ❑Door(s) ❑ Remode! ❑Water Damage <br /> nninnenana creek watersneo oistnc�(Mcwo� <br /> ❑Window(s) ❑ Rap�ir ❑ Stvrm Damage 18202 Minnetonka Blvd <br /> Dsephaven,MN 55381 <br /> ❑Siding ❑ Restoration ❑ pther:(spocify) Phone: 95z-a71-p590 <br /> Fax; 952-471-0682 <br /> Ra-roof ❑ Flre D�mago www.minnehah�cr�ek.orq <br /> Overall Project Description: <br /> �stlmated Construct�on Va�uatlon of P�oJect(excwding lane) S 3 G, r�%�� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information re9uired or requested by the Building Department; <br /> ■ Certifies that the information supplied is true and correct to the best of his(her knowletlge. The applicant fecognlZes�hai[hey <br /> are solely responsible for submilting a complete application being aware thal upvn failuro to do so,tl,e staff has no afternative <br /> but to raject it until it i�oompleta; <br /> • Some or all of th�information that you are asked to provide on this application is classified by St2te law as either private or <br /> confidential. Privale data is information which c�enera(ly cannot be glven to lhe pubilc Dut can De g�von to tnc su�jec[ or�ne <br /> data. Cvnfident�al data is informat�vn which gcncrally rannot bc given to cither the publiC or the subject oF [he deta, Ouf <br /> purposs and intended use of this informstion is l0 2nnually update our reCords and recArds of othvr gpvpmmontal agoncips <br /> re uired b la�ou refuse to supply the information, tho application ma not be issued. <br /> Applicant's Signaturc: L'`���� Date: ��/2 z.�io <br /> � <br /> Lsel Updsled: OS-D�}-2009 <br />