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Nov 08 10 10:12a Phillip Goettl 3208644084 p.1 City of Orono r . Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Ma�lingAddress: permitnumber: �7/d'd/� '�1 O•¢,Q,�.O PO Box 66 Crys�a! Bay,MN 55323-0066 Date received: �� O StnaatAddress: Received by: � 2750 Kelley Parkway Plan re�iew fee: ��° Orono,MN 5535B � Total Fee: /� � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This applicat�on form must be completed in full and all requirecf information must be submitted. Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: Job Site Address: C� . ��1 v'e Wi�l this be a Parade of Eiomes, Remodelers Sh case Home or other Display Home? Yes No If yes,a speclal evient permit ia required with Police Department and CityCouncil approvaf 60 days prior to the evenL Shutde 6us service will be r�quired unless appJicant demonsfralss su�cient on-site parking is avai/able. Non-permiKed events will not be a!lowed. CONTRACTOR/APPLICANT INFORMATION: Name: -��' 1�,� ('�,t��frc•r._��.� State License# aU�,3 i�...� Expirafion Date: 3 -/—/� Phone: (�%� !'�5�t 3 7� (office) -� (cell) Mailing Address: w�i?� � Ci : ;,/r;.,;�� ZIP: ;��"� � Cont�t Person: '� Applicant is: ractor � Homeowner �c��ie one� Email and/or Fax: �1��,�,�p �. e•r. o�►'� �: �� 4�`,� 5��i'� --� fi�� PROPERTY OWNER INFORMATION: Name: f/�,^,r,f �r� �v►�Yl Phone(day): �'�— U v r� Address: 3(0`� L,_uin.�y�-o�� -t- City: �h5,rl c�' ZIP: �5 J� Email andlor Fax PROJECT 1NFORMATION: Type�f Projeet: My earth movement may require MCWD review S permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑Stortn Damage 18202 Minnetonka Blvd Deephaven,MN 55391 ❑ Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 e-roof ❑ Fire Damage vr�vw.minnehahacreek.or4 Overall Pro�ect Desc�iption: Estimated Constructiort Yaluation of Project(excle�ding land) $ �-J�F�t% ,�% APPLICANT ACKNOWLEDGEMENT: • Agr�ees to provide all information required a requested by the Building Department; • Cefifies that the i�ormation supplied �, true and coRect to the best of his/her knowledge. The applicant recognizes that they ar�e solely responsibfe for submitting a complete application being aware that upon failure to do so, the stafF has no altemative but ta rejed ik until it is complete; • Some or alf of the information that you are asked to provide on this application is class'rfied by State law as either private or corfiden6al. Private data is iniom�ation which generalty cannot be given to the public bui cao be given to the subject of the data. Confidential daCa 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 agenaes r uired b law. If ou refuse to the inform ion t a licatiom m �ot be issued. Applicar�Ys Signature: Date: / � � '"l� �