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� �yed Ir�}e ;�J 1b 33-t1 S Z3 •t2. -*qa�� <br /> , <br />. . .. , . w4,,�,c-�, ce U,�.vt' 10 � <br /> ` C ity of 4rono <br /> Building Permit Application for Internal ork <br /> (windows, doors, siding, re-roof, etc.) <br /> r--_-" Mailing Address: aD!��+ 0D3� <br /> O��,�0 PO Box 66 Permit n mber: <br /> Crystal Bay,MN 55323-0066 Data ived: <br /> � Recei by: <br /> � ,� �"' Stneet Acldress: <br /> �.�, ° �� 2750 Kelley Parkway Pian revi fee: <br /> '�.��o�.$ Orono,MN 55356 <br /> - -- ,-�� : �aa i- ?9 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in fuli and all required information ust be submitted. <br /> Incomplete applications will be retumed. (P/ease prinf) <br /> GENERAL INFORMATION: � O 1 � S��/� <br /> Job Site Address: � �" � <br /> Wiil this be a Parade of Homes, Remodelers S owcase Hom r other Dis�ay H es No <br /> N yes,a specia!event permh/s required with PMice Depsrtment arnd City CounclJ 8pF►rova160 days�xror to event. Shtnde b�s service wr71 be <br /> requlred unless appllcant demonstretes sulAciant on�ite parking!s avaifable. Nw»pemutted ts wiH nof be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION� , r <br /> Name: G'1o�c{Ori e <br /> State License# Expiration ate: �.. f.. � 'Z, <br /> Lead Certification Number: � �-. Expiration ate: <br /> (for work on ho�»es that were constructed prlor to 1978 <br /> Phone: ('3 . (office) j 2 . Q'$q' — Z,C� (cell) <br /> Mailing Address: 3 City 4;,� ZIP: <br /> Contact Person: Applicant is: o tra r Homeowner (Clrcle Ona) <br /> Emait and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: `�'•�,, � !'ti +e P...�,�,'�' <br /> Phane(day): . <br /> Address: t,J. 'r'� -t;' City. ZIP: � �-(�,b <br /> Emai1 andlor Fax � � G• ��m <br /> PROJECT INFORMATION: <br /> Type of Project My eaK�movement may require <br /> ❑Door(s) ❑Remodel ❑Water Damage MC review 8 permlts: <br /> Minnehaha C ek Watershed District(MCWD) <br /> ❑Window(s} ❑Repair ❑Storm Damage 18 02 Nfinnetonka Blvd <br /> ❑Siding ❑Restoration ❑Other:(speclty) De haven, MN 553$1 <br /> P ne: 952-471-0590 <br /> ❑Re-roof ❑ Fire Damage x: 952-471-0682 <br /> . .min hahacreek.or <br /> Ove�all Pro'ect Descriptian: Q y� ,n,� ,QG <br /> Eatimated Constructlon Valuatio�of Pro'ect excluding land) ; p v <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all infoRnatio equired ar requested by the Building Department; <br /> � Certifies that the information ied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely respw�sible for su mi ing a complete appllcatlon being aware that upon failure t do so, the staff has no alternative <br /> but to reject it until it is com eta <br /> � Some or all of the inform tion at yau are asked to provide on this application is classifi d by State law as either private or <br /> confidential. Private is in rmation which generally cannot be given to the pu�ic bu can be given to the subject of the <br /> data. Confidenti ata s � ation which generally cannot be given to either the pub ic or the subject of the data. Our <br /> purpose and i nded u e of is infarmation Is to annually update our records and reco s of other governmental agencias <br /> re uired b I . If u r fuse u 1 the nformation the a lication ma not be issued. <br /> Applicant's Signature: Date: � 1� <br /> Last UPdated: 03-01-2011 <br />