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� City of Orono <br /> 1 <br /> � � Building Permit Application for Internal W rk ��� t1 <br /> � (windows, doors, siding, re-roof, etc.) <br /> �—_ � Mailing Address: Permit number: �/—v�D�O <br /> �0,�} PO Box 66 -- <br /> n Cr ystal Ba y, MN 55323-0066 D a t e r e c e i v e d: � �7 / <br /> 1� <br /> �^.�`'_�= 1 Received by: <br /> a �: �;z,,. I �, Street Address: <br /> �'�, ° '� ti 2750 Kelley Parkway Plan review fe <br /> '�9g�Kog� Orono, MN 55356 � � J <br /> �_-.—� i Total Fee: ���� / <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> T is application form must be completed in full and all required information must be su mitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INF�ORMATION: <br /> Job Site Address: oZ�a?0 KEL�Y f�tiRKw,9�Y - G(�vs !O Tav B�4 CavDcs <br /> Will this be a P�arade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No <br /> If yes,a speciallevent permit is required with Police Department and City Council approva160 days pnor to the event. Sh tt/e bus service will be <br /> reqy�ired unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not b allowed. <br /> CONTRACTORj/APPLICANT INFORMATION: <br /> Name: O s �tC .I'ON <br /> State License# � d�S 319b I Expiration Date: � �� <br /> Phone: ! 9- 3 I office (,� 3�q- 3 7� cell <br /> Mailing Address:i D X Cit : �E LN,Trv ZIP: SS3 9 <br /> Contact Person: �O� 1'►'►C PI�E�25�V Applicant is: Contractor / Home wner (Circle One) <br /> Email and/or Fa�: 'o� o - 'a+.�eS. <br /> PROPERTY OUI�NER I FORMATION: <br /> Name: tz E,u .Z"�vDEA�aAE�vT BANK <br /> Phone(day): ql _ <br /> Address: 00 tv. 3G�� 5�-. Cit : t. La�lS /AKK �P� SSy � L <br /> Email and/or Fa ✓fl tt � „ ,,�w�r�,�,.• K • , a,,., <br /> PROJECT INF RMATION: <br /> Type of Project: Any earth movemen may require <br /> 1 MCWD review permits <br /> �Door(s) *NtE�R?D �Remodel ❑Water Damage <br /> Minnehaha Creek Watersh d District(MCWD) <br /> ❑Window(s) j ❑ Repair ❑ Storm Damage 18202 Minneto ka Blvd <br /> Deephaven, M 55391 <br /> ❑Siding I ❑ Restoration ❑ Other: (specify) Phone: 952-4 1-0590 <br /> i Fax: 952-471 0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehaha reek.or <br /> Overall Project escription: F't�t/SSl� I�ECG S <br /> Estimated Cons�ruction Valuation of Project(excluding land) $ GS 000 ^ <br /> APPLICANT A KNOWLEDGEMENT: <br /> • Agrees to Rrovide all information required or requested by the Building Department; <br /> • Certifies th�t the information supplied is true and correct to the best of his/her knowledge. The applica t recognizes that they <br /> are solely r'esponsible for submitting a complete application being aware that upon failure to do so, the taff has no alternative <br /> but to rejecK it until it is complete; <br /> • Some or aql of the information that you are asked to provide on this application is classified by State I w as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be give to the subject of the <br /> data. Con�idential data is information which generally cannot be given to either the public or the su ject of the data. Our <br /> purpose ar�d intended use of this information is to annually update our records and records of other overnmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signaty�re: �rL Date: /—u? �/� <br /> Last Updated: 05-04-2p09 <br />