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� . ci of orono � 9 �'�• �� <br /> i � <br /> , � Building Permit Appiication for Internal Work <br /> � (windows, doors, siding, re-roof, etc.) �ti5$ <br /> MailingAddress: Permitnumber: �l�—�G <br /> �o� PO Box 66 <br /> ' ' � CrysYal Bay, MN 55323-0066n , �..� Date received: � <br /> �/O � O� <br /> '� =����., 1, � u A- <br /> '� ���•' Received by: <br /> ,a t �? � s,� StreetAddress: <br /> ��'.�,r ��,�Gti 2750 Kelley Parkway � � Plan review fee: � �. <br /> �����:�g Orono, MN 55356 I �I <br /> ESH� o�c�//- v <br /> Total Fee: �-3 <br /> Main: 952-249-4600 Fax: 952-249�616 <br /> This app{ication form must be completed in fu{I and a{I requi�ed informa#ion mLst be subrr�itted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERALINFORMATION: � 6 �j�11,��� GN � 2�'�) ��V yJ�� I <br /> Job Site Address: n � , <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No <br /> If yes,a specia/everrt permit is required wifh Police Department and Cify Counci!approvat 6Q days prior fo the event. Shuttle bus service will be <br /> required unless app'icant demorrstrates sr.fficierd on-site parking is availa6le. IVon-pem�ifted events wiN not be allowed. <br /> CONTRACTOR/APPLfCANT INFORMATION: <br /> Name: GFf✓LJ4t�Lrl'Z- ' L'o�/��1NIE5 <br /> State License# Z�C L�?�t}7,?� Expiration Date: 3,� �Z <br /> Lead Certification Number: �-.r_ (� �i5'-�� -�����L., Expiration Date: • -• -� <br /> (for work on homes that were constructed prior to 1978 / - <br /> Phone: 9 Z• 6 • Z (office) b(Z• ��' 9� (cell} <br /> Mailing Address: � E�CL .. 02 QrLI/ #� 0 c�ty:5�: t,.u�s PR�t.Jc ZIP: 1�}�(p <br /> Contact Person: AN�N Qa BR�oH Applicant is: on ra r / Homeowner (CircleOne) <br /> Email and/or Fax: � �R p�y �q SC n 1�p4►� Ca M�P�4A/lL S . �1'�'1 <br /> PROPERTY OWNER IN�ORMATION: <br /> Name: �C�L[.'� # 1)�VE 2/Lslc LC'� <br /> Phone(day): 93rf• 2/!,�• �Z$7 � j ` <br /> Address: 11gd N�h.irw��s l�l� C�tY= W��214TIA ZIP: J� 39� <br /> Email and/or Fax keL�H �„_ (Z(S C NLS � C�1LC��L l. . C o W► <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review& permits: <br /> ❑ Door(s) Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑Restoration ❑Other:(specify) Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> Overall Project Description: J'{� �/�/ (�pd fL � d pj�i j,i (,��p/�T� <br /> Estimated Construction Valuation of Project(excluding land} s A C� �pp <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to�e best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> but to re}ect it until it is complete; <br /> + Some or all of the information that you are asked to provide on this application is classfied by State law as either private or <br /> confide�tial. 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 information which generaliy cannot be given to either the public or the subject of�e data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refu I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: ta. Date: l,v/�-1 � I <br /> Last Updated: 03-01-2011 <br />