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Cit of Orono �I� � �� <br /> y <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: a v/(� —(�Q �p <br /> �0,�. PO Box 66 Permit number: <br /> Q � � Crystal Bay, MN 55323-0066 Date received: � 02 O �� <br /> �`'`i "�� Received by: `� <br /> a �', �;�;' �,� StreetAddress: <br /> ��, ' ` Gti``' 2750 Kelley Parkway Plan review fee: <br /> .� �� Orono, MN 55356 � <br /> t kEsso� <br /> �-_-_" Total Fee: ��� �9' <br /> Main: 952-249-4600 Fax: 952-249-4616 "s <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 2?5 �{oLL�-�"7�2 ^��4� <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 required with Pollce Department and City Council approval 60 days pnor to the event. Shuttle 6us service will be <br /> required unless applicant demonstrates sufficient on-site parking rs avarlable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: , <br /> Name: �7 A1 �cr� "pFcs�ly,N��+-���-� I NL , <br /> State License# 8�o Expiration Date: � Zol 1 <br /> Phone: 9SZ-�1 Z�i--�5 �C� (office) (Q/Z-�2 3 -�i o (cel l) <br /> Mailing Address: t t,,v� Cit : ��in.�+4 ZIP: -r,�-5'L{-1 <br /> Contact Person: '��,.��� �j ��,[5►c� Applicant is: ntractor / Homeowner (Circle One) <br /> Email and/or Fax: '�i nc.s��.��,.��e���,ur-c�z.�i�- ,�.)�'r <br /> PROPERTY OWNER INFORMATION: <br /> Name: �n� 'k���� � Un�o�, (p"'(����-�. <br /> Phone (day): %52-�}�co�'8 ceo Z <br /> Address: �.�� ,�o�a,�,���-Q f�vr� City: 62-r�r-[o ZIP: S' S3q I <br /> Email and/or Fax (�r.�(0_c-�Cu�s� , Cr�r--� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�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 �J .�'��a � � � <br /> Overall Project Description:�rz,.�ov�-r�� �}c�sTr�l� Lc�u��;� LZ-riL-� �A-T�- <br /> Estimated Construction Valuation of Project(excluding land) $ /O,O�o. c�� <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 co�rect to the 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 altemative <br /> but to reject it until it is complete; <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 information which generally cannot be given to either the public or the subject of the 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 refuse to su I the information,the a lication ma not be issued. <br /> . // <br /> Applicant's Signature: --�� �' ' ' Date: � z� �/ � <br /> Last Updated: 05-04-2009 <br />