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� ��- ;� �.. ; � - � " City of Orono �� , � ��,�� � � ,x� u;.� ��j'.; . Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) `` � Mailing Address: Permit number: /O—��3 4v�,� PO Box 66 ' �,;�y Q Crystal Bay, MN 55323-0066 Date received: �.��P�o ' `�s,�� . �' a �' ��" a Street Address: Received by: �� 4 AG.,.:';y �'�,n � A" G� 2750 Kelley Parkway Plan review fee: � L`�gESKo�`'� Orono, MN 55356 � — Total Fee: a`a� „A� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ;�� This application form must be completed in full and all required information must be submitted. � Incomplete applications will be returned. (P/ease print) �� GENERAL INFORMATION: �; � Job Site Address: 1\6 �ti-� ST � � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No � If yes, a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be � required unless applicant demonstrates sufficienf on-site parking is available. Non-permitted events will not be allowed. ;� � CONTRACTOR/APPLICA T INFORMATION: ��' Name: �r C' S��SI�c�C C�ns�- State License# �Zn 3� 6 37 3 Expiration Date: - "3 �I � i 1 ` Phone: �6 3, 23Z- 2`�1 office �6�- 2,3 L- 231-C cell � �;,; Mailing Address: �523 �'�-l�s �: Y . Cit : -f-f ti(o rn Z�P: S ��3!3 Contact Person: �y,pr � Applicant is: �� Contracto / Homeowner (Circle One) Email and/or Fax: � PROPERTY OWNER INFORMATION: � Name: i�e G�v.� c�ba��s ` Phone (day): Address: �l v (�., S T- City: � i �n �, ZIP: �� Email and/or Fax :,� PROJECT INFORMATION: �`.� Type of Project: Any earth movement may require � MCWD review&permits ❑ Door(s) ❑ Remodel ❑Water Damage �' Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd •� Deephaven, MN 55391 ,� ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 � E ` Fax: 952-471-0682 � �Re-roof ❑ Fire Damage www.minnehahacreek.orq Overall Project Description: '1 e�� -{-f- hv,s�,�. G�f{y� ( i (�.,{; -� �.�sl�, �� a Estimated Construction Valuation of Project(excluding land) $ 11 �p�C, �; �� APPLICANT ACKNOWLEDGEMENT: � • Agrees to provide all information required or requested by the Building Department; t� • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they `� are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative .� but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or �-� confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �� data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our �`�= purpose and intended use of this information is to annually update our records and records of other governmental agencies ��'� re uired b law. If ou refuse to su I the information, the a lication ma not be issued. ':� :� A , �z` Applicant's Signature: �� Date: S �Z� � � � x �.` ;,� � :,- >ti. Last Updated: 05-04-2009 '�� ;. : � � �,'�, �—�'4 � : L y i _ .., _ . .. .., .��-�§._. s .wt�3s.zu ax,tE v= ..x �,�.,,�,4§.:xY'E4.y��"1`�.�[:3„.,.Se. �