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City of 4rono <br /> Building Permit Application for In#ernal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> ��O� Maiting Address: /�! � / / <br /> PO eox 66 PermlC number: �/ <br /> �Q +� 0 Crystai Bay,MN 55323-0066 Date received: c� /Q— <br /> � ��%' Fteceived b � <br /> 5treet Address: Y� --P,YVt- <br /> �.�n` ' �t��� G� 2750 Kelley Parkway Plan reView fee; / ��d�/ <br /> �9rr�sH� Orono,MN 55356 �y, <br /> ' Total Fee: '�" � O �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci,orono.mn.us � �O 9. <br /> This application form must be completed in fuli and all required information must be submltted. <br /> incompiete applications will be returned. (Please prrnt) �i�•�fr//,jl�.— (,1J1IU.7t— <br /> GEN ERAL INFORMATION: 3�� <br /> Jpb Site Address: �, � S O � � <br /> Will this be a Parade of Homes, Remodelers S owcase Hom r other Display Ho e? es No <br /> /f yes, a specia!event pemilt Is requlred wlth Police Department and City Counc!!approva!60 days prior to fhe event. Shutlle bus servlce wili be <br /> requrred unless appllcan!demonstreies suillcie»f on�fte parking Is avalleble. Non-permitted events will nof be alfowed. <br /> CONTRAC70R/APPLICANT INFORMA710N:/� <br /> Name: G'1c�1'c�pt'� w VYLe.S t---oY�S���✓1 <br /> State License# ���(�___T Expiration Date: �3_�� j �-� <br /> Lead Certification Num er: �b �-. Expiration Date: � <br /> (for wor k on ho►»es that were constructed prlor to 1978 <br /> Phone: ('3 . . (o�ce) j Z. - gg� "'7�, Z.(.�c (cell) <br /> Mailing Address: , '� City. 4;,� ZIP: <br /> Contact Person: Ld. ►� Appiicant is: o tra r Homeowner <br /> Email and/or Fax: (cir�ia o�e� <br /> (.l.)t �.�. ar7�[�(' Y� -�'c�w+�e S C t�� <br /> PROF'ERTY OWNER INFORMATION: ./� <br /> Name: C- �'� S � t18�P�2�ev�-"�' V�'.�v�.� <br /> Phone (day): GjS--Z �.l�- • ��,�-�_ <br /> Address: �-� � �6'�+ �-1-� City. � ZIP; <br /> Email and/orFax • � ��S ��� ����� <br /> -� �dl.v� Sl�o Qf��l� i .�'�b.ns"�P�'nS�/ L'�JA-�Ic-C�h •Co►✓� S'S�- �IS ��6 <br /> PROJECT INFORMA710N: <br /> Type of ProJect: Any earth movement may require <br /> ❑Door(s) ❑Remodel ❑Water Damage MCWb review&permtts: <br /> ❑Window(s) ❑ Re air Minnehaha Creek Watershed District(MCWD) <br /> p ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Restoration Deephaven, MN 55391 <br /> ❑Siding ❑Other:(speclfy) <br /> Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-OS82 <br /> www.mfnnehahacreek.or� <br /> overall Project Description: <br /> _Estimated Constructlon Valuatfon of Project(excluding land) $ � __ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all inforrriatlon required or requested by the Building Department; <br /> � Certifles that the information supplied is true and correct to the best of his/her knowledge. The applicanf recognizes that they <br /> are solely responsible for submitting a complete appllcat n being aware that upon fallure to do so, the staff has no alterna tive <br /> but to re]ect it untii it is complete; <br /> � Some or all of[he inform lion-that you are asked/t provide on this application is classified by State law as either private or <br /> confidential. Private d a is informat(on wh,lcFi g nerally nnot be given to the public but can be given to the subject of the <br /> data. Confidential da a Is information���ch g�erally �nnot be given to elther the public or the subject of the data. Our <br /> purpose and intended use of this info atio��s to an (laliy update our records and records o(other governmental agencies <br /> re uired b law. If ou l�efus u ��the fifo ma' ,the a Ifcatfon ma nof be issued. <br /> Applicant's Signature: � - Date: � '/ <br /> -....,.- <br /> Last Updated: 03-01-2�11 <br />