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�.1,'1�,_2010 11:17 5156616336 PAGE 01/01 � City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailinq Addr�ss: Permit number� f�ld—b/� � � ��Q�\ PO 6ox 66 L.. >,•� Crystal Bay, MN 55323-�066 Date received: I b D il �i'�;p�:,:,., �, Received by: i �'� �,, Str�et Address: �� nsr,;,. � `�,� ti l 2750 Kelley Parkway Plan review fee: `�C�yJ �s�'�" °�� Orono, MN 55356 � 9kE$IIOg� /�� ✓ __ . Total Fee: 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 submiited. Incomplete applications will be returned. (Please print) GENERAL INFORMATION� Job Site Address: 0 0 LOm4 l,indct-- - � ound /� 5s3� Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home? ❑ Yes No If yes,�Spec�al event permit is required with Police DepaRment 9nd City CounCll approve/60 days prloY fo the event. Shuftle bus service Wrll be required unless applicant demonstr�tes sufficient on-site par'king is available. Non•permitted events will not be allowed. CON7RACTOR/APPLICANT INFORMATION: Name: G7�� Cd t A�'tM df' 7�)11Q State License# Z�S / Expirahon Date� �1_ 0 Phone: - - office cell Mailing Address: v 0 Cit : ZIP: ContaCt Person: Applicant is: Contractor Homeowner (Clrcle One) Email andlor Fax: c1�s .L�tc r��3'�Y'G �1S " � " PROPERTY OWNER I�N 1�MATION: Name: Phone (day}� - / a Address� D 0 � ��t : �'1 hd z1P: 553 Email and/or Fax PROJECT IN�ORMATIQN: Type of Projsct: Any earth movement may require MCWD review 8 permits ❑Door(s) ❑ Remodel ❑ Water Damage Minnehaha Creek Watershed District(MCWD) ❑Windo�v(s) ❑ Repai� ❑Storm Damage 1$202 Minnetonka Blvd Deephaven, MN 55391 ❑Siding ❑ Restoration ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 Re-roof ❑ Fire Damage ___________________.. www.minnehahacreek.orca Overall Project Description: f /'.�e lat.e . .$ Estimated Construction Valuation of Project(excluding land) $ aS APPLICANT ACKNOWLEDGEMENT: .. . Agrees to provide all information required or requested by 4he Building Department; • 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 alternative but to rejecl it unlil it is complete; . Some or a�l of�he information thal you are asked to provide on this application is classlfied by State law as either private o� � confidential. Privat� data is information which generally cannot be given �o the public bu� can be given to Ihe subject of the 1 da�a. Confideniie� data is informetion which pgnerally cannot be given io either the public or the subjec[ of the daSa. OUr purpose and inlended use of this information is to annually update our records and records of other governmenial agencies re uired b law. If ou refuse to su I the information, the a lication ma not be issued. Applicant's Signature; Date: ^�I f D�� LaslUpdated; 05-Oa-2009