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<br /> City af Qrono
<br /> Building Permit Application for Internai Work
<br /> (windows, doors, siding, re-raof, etc.} '
<br /> tl���O-��\ MailiPO Bo�r66• Permit number. D� ��vs�
<br /> �y
<br /> Q,�x Crystal Bay, MN 55323-0066 Date received: �O
<br /> i�,� �. �,1+ SfreetAddress: Received by: ^� d, .
<br /> ��� t � { ti�' 2750 Kelle Parkwa
<br /> � Y Y Plan review fee:
<br /> \�g �� Orono,MN 55356 Q i
<br /> F:sxo� �U�. ��
<br /> �`'--'� Total Fee:
<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 be submitted.
<br /> Incomplete applications will be returned. (Please print) ,
<br /> G�NERA�INFORNIATION:
<br /> Job Site Address: � .3v4NttST�.�W� �r�
<br /> WFiI this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o
<br /> tf yes,a specia/everrt permit is required with Palice Departmenf and City Council approva!60 days pr'ror to the event. Shuitle bus rv' wiN be
<br /> required unless applicant demonstrotes s�cienf on-slte parking Is evallad/e. Non-permitted events wrll not be aJlowed.
<br /> CONTRACTOR/APPLICANT INFt3i2MATION:
<br /> Name: �� � `�Q...t �L L,.C..�-
<br /> State�icense# ~?�,t„�'����,,, Expiration Date: �—�/-Zd�-Z,,
<br /> Lead Certification Number: R,r ���� - �f_���,I S Expiration Date: 3��.�,a�
<br /> (for work on homes that were constructed priar to l978 �
<br /> Phone: Cp t Z- '�.��- £3(0(9 (office) (cell)
<br /> Mailing Address: ( �� ��,",rd ,4,,,, ��, City: � �IP: ,5'��$
<br /> Contact Person: ^�"'��,� F--�� Appficant is: ontracto / Homeowner �c��oi�000t
<br /> Email and/or Fax: ��,p�� ����.�-��.C�;r,.�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: f�inlLl.�! �.�'Ut--i� ��' �
<br /> Phone(day): �j�Z _� � �j+�
<br /> Address: ��5� _"C�ydrrF�T�s,,,�,J (�,o� City: �Y��kj ZIP: �",�'� �o ;
<br /> Email and/or Fax ,,��p�_ p����,;rt���rM�
<br /> PROJECT INFORMATIQN: Nr�?c�- S/JJ(�C„�
<br /> Type of Project: Any earth movement may require
<br /> ❑Door(s) ❑ Remodel ❑Water Damage MCWD review 8�permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Window(s) ❑Repair ❑Stortn Damage 18202 Minnetonka 61vd
<br /> ❑Siding ❑Restoration ❑Other.(specify) Deephaven,MN 55391
<br /> Phone: 952-tt71-0590
<br /> e-roof ❑Fire Damage Fax: 952-471-0682
<br /> www.m i n nehahecreek.oro
<br /> Overail Praject Description: '
<br /> �stimated Gonstruction Valuatlon of ProJect(excluding land) $ �,a��----�
<br /> APPLICANT ACKNOWLEDGEMENT;
<br /> • Agrees to provide all information required or requested by the Building Qepartment;
<br /> • Certifies that the information supplied is true and correct 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 generalty cannot be given to the public but can be given to the subject of the
<br /> data. Canfidential data is information which generally cannat be given to either the public or the subject of the data. Our ,
<br /> purpose and intended u ' formation is to annually update our records and records of other governmental agencies
<br /> re uired b law. If o efuse Uo su I the information the a lication ma not be issued.
<br /> Applicant's Signature: Date: �O``Z.�-l"7—c�j/
<br /> Last Updated: 03-01-2011
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