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AUG. 29, 2012 1 : 02PM SHAW/STEWART LUMBER 6514884791 N0. 079 P, 2 � - Cifiy o� Orono Building Permit Applica�ion for Internal Work (windows, doors, siding, re-roof, etc.) .�,�,� M�,II PO Box 66, Perrr�it�number: O O Crystal 6ay,MN 55323-0066 Da'fe received: � a Stree!Address: Receiv�d b,y: G� 2750 Kelley Parkway Plan revaew fee: �,�g�og� Orono,MN 55356 � Tbtal FOe: Main: 952-249-4600 Fax: 952-24914616 www.ci.orono,mn,us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned, (Please print) GENERAL INFORMATION; Job Site Address: 2y4 S �/�6xk C,A�E eD Will this be a Parade of Homes, Remodelers Showcase Home or other Display Mome? Yes No If yes,a speciel event permit Is required with Police Department and Gty Council approve/60 days prior to the event. Shuttle bus servica wlll be rt�quired unlass applicant demonstrates su�cient on�ite paiking is availsb/e. Non•permitte�d events will not be al/owed. CONTRACTOR/APPLICANT INFORMATION: Name: 1-�Ae,Motwt l�� s lN�• State License# 50�'��3 Expiration Dete: 3�� ?�0►3 Phone: �Lo� y13.1►00 (o�ce) CQ'�Z• 455•SZ3d (cell) _ Mailing Address: t 4Zo w��r�G ST � City; wt�S Z1P= SS'�i i3 _ Contact Person: GH-�aS M�(�2�� Applicant is: Cohtf r� / Homeowner (Clrcic One) Email and/or Fax: G�c�,w+�rsl�•�+a,.•t +Sl-��-�1�• �'�'� PROPERN OWNER INFORMA710N: Name: �ORN �� Phohe(day): 20-�� $yCv. cov$ Address: z�ic.5 c�McF RD City: �120�+o ZfP: S53°l � Email and/ot Fax PROJECT INFORMATfON: Type of Projert: Any earth movemen't may require MCVNb review&permits ❑Door(s) �emodel ❑Water Damage Minneh�ha Creek Watershed District(MCWD) [�lrindow(s) ❑ Repair ❑ Siorm Damage 18202 Minnetonka Bfvd Deephaven,MN 55391 ❑Siding ❑Restoration ❑Other:(specify) Phone; 952-4,71-0590 Fax: 952-471-0682 ❑ Re-roof ❑ Fire Da�mage www.minnehahacr_ ek.orq Overall ProjeckDescription: �.aS�TwrK q w��bc�s �.+ d�c��T� opc.,qNGs Estimated Construction Valuation of Project(excluding land) $ � I� S 73.�a _ � APPLICANT ACKNOWLEDGEMENT: . Agrees to provide afl information required or requested by the Building Department; • CeRifies that the information supplied is true and corred to th� best of his/her knoWledge. The applicapt recogniZes thaY they are solely resppnsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to reject it until it is complete; � Some or all of the information that you are asked to provide on this application is classified by State law as either private or con�dentia�. Private data is information which generally eannot be given to the publie but can be given to the subject of 4he data. Confdential 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 annual update our records and rewrds of other govemmental agencies re uir`ed b law. If ou refuse to su I the info tion, a lication ma not be issued. ! Applicant's Signature: Date: ��ZQ/'2 Last Updated: 05-04-2009