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City of Orono `3 z�-�� <br /> . � Building Permit Application <br /> Mailin Address: aOD9 �p <br /> �,��� `\ PO Box 66 Permit number: Q/ <br /> � Crystal Bay, MN 55323-0066 Date received: 3-2 -D 9 <br /> ,��y., �0 �� <br /> `�t,�,P._ <br /> I �= �-,- �; Received by: <br /> (,� �,���s-. s,� StreetAddress: <br /> ��',�, ,�. ����°���� ��� 2750 Kelley Parkway Plan review fee: <br /> L�y�Es� ¢,�v � Orono, MN 55356 <br /> � <br /> Total Fee: a 7� 7 / <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 b submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �, � � i�t �% �2c:wcJ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> If yes, a specia/event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be <br /> required unless applrcant demonstrates sufficient on-site parking is avarlable. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: -F.� ,--_- _.�F3-� c��n,� C a.l�c Lo�.�--�-r� .3(C�t"S <br /> State License# a� � �c, (o �� Expiration Date: 3/3,t/o�oo9 <br /> Phone: (P)�-�17�Sb�'O (office) ���- y 7 y- 7��� (cell) <br /> Mailing Address: '� �� ���n sj City: �x�St�s: ��. ZIP: S S" 3 �i <br /> Contact Person: ��7-.� S,,t--�,���s.�,,_: Applicant is: Contractor / Homeowner (Circle One) <br /> Emailand/orFax: �r--rc �2S��..t��,�w � �,�i1rc���,���Z� �'���,�_J-��2_< ac�<� ;�� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �R 1�, �� ��` <br /> Phone (day): �7- ^ - <br /> Address: � '7� �r,L �n��.�,� u ; � (� CitY� G>P��� ZIP: � S 3�� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) � Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: ��j��--� �� c�y�L� s % n- si'�c �vv,Z �-�g-- <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> �`y <br /> APPLICANT 8� OWNER ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department, <br /> • Certify that the information supplied is true and correct to the best of his/her knowledge. The applicant and owner recognize <br /> that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff <br /> has no alternative but to reject it until it is complete. <br /> • The Owner hereby acknowledges and agrees to this application and further authorizes reasonable entry onto the property by <br /> City Staff, consultants or agents, for purposes of investigation of this request. <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is informatio� which enerally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended us2 of this info tio�s to annually update our records and records of other governmental agencies <br /> re uired b law. If o refuse to su (� e:mformatio ,the a lication ma not be issued. <br /> Applicant's Signature: '\ �'" . %' � /i�-� Date: ��,��6 j_. <br /> �.._.. - <br /> :` <br /> Owner's Signature: � ,� Date: <br />