Laserfiche WebLink
City of Orono <br /> Buitding Permit Apptication for In#ernat VI/ark <br /> (windaws, doors, siding, re-roof, etc.j <br /> M�rling Addr�ss: �a _Q� C� (� <br /> �`��;d,�1jO Pp Box 6S ' Permif number �(> / <br /> ► <br /> ��/ Crystal Bay,MN 55323-0066 � Data received: �I/ �j/�j <br /> � � ,.« Re.�eived by: `� <br /> + a r+ m SfreetAddress: <br /> �,�� � �` G�' 2750 Ke�iey Parkway F'lan reYiew#ee: _ <br /> �' Orono,MN 55356 f <br /> �b.SHpi <br /> + T6t81 FeA: � � l i � G` � <br /> Main� �"i2-249-4600 Fax: 952-249-46'i8 www.ci.orono.mn.us 4 ��5` - /;yr�;;. <br /> This applic�tian form must be complet�i in full and all requireri infarmation must be subrnitted. �;_�j/Z <br /> incomplete applications will be returned. (PJease print) <br /> GENERAL IFlFClRMATIOI�t: <br /> Job Site Address: ['� S O (✓'4�',� <br /> Will this he a Pa�ade of Hames,Remodelers S owcase Ho r ather Display N e? es No <br /> !f yes,a spacial eveni pe�mit is saquired with Potice Departrrrerrt eRd Gty Counci!ap{xovat 60 days priar 2o ihe event. Shtrttte bus servtce wil'be <br /> requtred unlass applicant demonsfretes sulhaient onsita parking 15 avaNsbte. Nonpermitted events wi!!not be adowed, <br /> CaN7RACTOR/APPLlCANT!hlFORIIAA7IQN:/� -.� .�.�� <br /> Name: ��lo�'c�o2^�.�VYte.� �--l�v� �TY�.tJll�Y'� <br /> 5tate License# �S+-3 4�[,�{ Expiration Daie: �,- t.- � "� <br /> �ead Certificatian Number; �t �. Expiration Date: <br /> (for wark on homes tha t were constrcrcted prior to i978 <br /> Phone: L�'7y, - { (a�ce} �2 - �''� '"?�,�L. (cel{} <br /> Mailing Address: 3 Gity ZfP: �-,� <br /> Cantact Person: A licant is: o tra �� Ho eowner <br /> PP _��o-� j-i-- <br /> Emait andlor Fax: <br /> PROPERTY OWNER iNFt3RMAtION: 1 �n <br /> �4arne: `r' ���t Y�"�..,n� <br /> �S__� r� Q e�.�t"' <br /> Phone(day): L � <br /> Address: �dC�n W• 3�,''�'' S`fi' c�t_y�-��S�c�zrP: �S �l!.� <br /> Email and/ar Fax ��r�y� ���Q,f-- yvvb��,�br�.v,n�r.,�er-�?�.�(�,i,�,�,,� G��__ �l;C>CJm <br /> PROJECT INFQRMATION: <br /> Type ef Pro]ect: Any earth moverx�ertt may reqc►ire <br /> MCWD revtew 8 permits: <br /> ❑Daor(s) ❑Remodel ❑WaterDamage �;nnehaha Creek Watershed District(MGWD) <br /> [}WincSow(s) ❑Repair ❑Sto+m Damage 182021v1'innetonka Blvd <br /> ❑Siding ❑Restoratian ❑Other:(speclfy) aeephaven,MN 55391 <br /> ❑Re-roof i Phone� 952-47i-0590 <br /> ❑Fire Damage Fax: 9�2-�t71-OFi82 � <br /> vrww.minnehahacreak.ors� <br /> Overail Project Description: � ,r, �;,;,,• �/ "' <br /> Estimated Construction Valuation of Project{excluding iant!) � 6�r�Z�.s�, <br /> �� - <br /> APPLICANT A�CKNOWLEDGEMENT: <br /> Agrees to pravide afl infa►matian required or r^equested by the Building Department; <br /> � Certifies that the information supplied is true and correct to the best of his/her knovuiedge. i"he applicant�cagnizes that ihey � <br /> are so�ely r�esponsible kx subrraittirtg a complete appficatlon being aware that upon failure to c�so,the sta�`has no aftema tive <br /> but to reject it until it is complete; <br /> s Some or af4 af the 1nfoTrr�atron that you are aske�5 ta provide on this appiication is ciassified by State iaw as either pnvate or <br /> confidential. Private data is infortnation which generally cannot be giuen to the public but can be given to the subjecl of#he <br /> data. Confidential da2a is informatlon which generalty cannot be given to either the public or the subject af ine data. Our <br /> purpnse and int+ended use of this information is fo annualty update our necords and records of othet governmental agencies <br /> re uired b law. If u refuse su khe information,the a Eicatian ma not be issued. <br /> Applicant's Signatu�e: � Date: ��-��--�(�J � <br /> tast UpdateJ: Q3-OY-20i 1 f �` <br /> / <br />