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�k. ' . . , ' 1 • . . <br /> . City of'Orono <br /> 6uilding Permit';Ap►p�ication f�r Internal Wo�k <br /> . (Wi17dQWs� d�o1"Si siding;y re-roof, etc.) <br /> Mailing A�Jdress- ' ' Permit number. / <br /> �g o� ,Po�as . .� <br /> 0 Crystgl Bay,MN 5532�OQ66 Date rec�ived: � a!O <br /> � � SlhaetAddress: Received by: <br /> 2750 Kelley Parkway Plsn r+eview f�e: � <br /> '�g �4' Oror�, MN 55356 <br /> Total Fee: � ��(J, �� <br /> Main: 952 2434600 Fax: 95Z-249-4616 www.ci.orQno_mn.us <br /> This applica�on fonn must be completed in full and all required information must be submitted. <br /> Ineomplete applications wlll b�retumed. �(Please print) <br /> GENERAL INFORMATION: .�� , v i �� . ^ , rG�� <br /> Job Site Address: � <br /> Will thf� be a Parade of Homes, Remodel�rs Showca orri�or other�isplay Home? Yes No <br /> N yes,a speCJal event perrnit is raquired w�t Pofia�Oeparhnenf end Ci y'Cou�CJ/9pprova160 days prior bo the event Shutile bus servke wil!be <br /> requfied uNess app/icant demansLrates�ulficient on-�!e pe(ki►rg is avallaWe. Nan-permilted evsrrta wi11 rtot be a/lowed, <br /> ;, , � ; <br /> CONTRACTOR I ApPLICANT INFORMA710N:.: ` '" <br /> Name: '�' 1rGa t�►V+r1 �1r1 � <br /> State License# ,.:�, , , ! � ,< , , Expiratian Date: �1 <br /> Phone: —""'1 '�— ` office cell <br /> Mailing Address: '-10G1 C' : ZIP: <br /> Contact Person: ` �, Applicant is: Contractor / Homeowne� �c�rcro a,o► <br /> Email andlor Fax; $O� --1 a(�—�e 1�10� <br /> PROPERTY OWNE�t INFORMATION: <br /> Name: JG ' i <br /> Phone(day): — — � <br /> Address: �='j ` Ci :� �,Gt� ZIP: Gj <br /> Email and/or Fax <br /> PROJECT IN�ORINA'170N: <br /> Type of Project: ' , Arnr�arth movemerrt may requlrie <br /> ❑ Door(s) ❑Remodel MCYVD review S permils <br /> �Water Damage �.�; <br /> �` ' Minnehaha Craek Watershed Distriet(MGWD} <br /> [I Window(s) ❑Repeir ��]Storm Demage � i 18202 Minnetcnka Blvd <br /> ' � � � � � Deephaven,MN 55391 <br /> ❑Siding ❑Restoration °;a��`J Other-(speafjr) y ' �, ;" Phone: 962-471-0590 <br /> • I ', , ' Fax: 852-471-0682 <br /> Re-roof ❑ Fire Damage w_ww,minnehahacr�l4.org <br /> Overall Project Qescription: v � <br /> Estimated Construction Valuslion of Pro ect excluding land) $ <br /> APPLICANT ACKNOVYLEDC3EMENT: <br /> • Agrees to provid�al)infortnation required or requested by 1he Building Department; <br /> • Certi6es that the infarmation supplied is true and cflRed to the best of hislher krmwledge. The spplic�nt recog�izes that ihey <br /> are solely responsible far submltting a compl�te applicadon being aware that upon failure to do so, the staf�has no altemative <br /> but to rejeet k until it is cnmplete; ' <br /> • Some or all of the information that you are �sked to pravide on this applic�tion is dassifled by State 18w es either p�ivate a <br /> cor�iderdlal. Private data is lnfonnstion which ger�aly cannot be given to the publtc but can be given tc the subjed of�e <br /> data. Confidentiel clate is inforn�atian which generally canhot be given to either the public or the subjeCt of the data. Ou� <br /> purpose and intended use of this informat'ion,is to annually update our tBlcords and reoords of ofher govemmental agendes <br /> uired law. If u refuse to su ' the' ony s lic�tion not be issued. <br /> ^'_'.— ; , i <br /> ;, <br /> � ; �� ' <br /> i � � � �� � , <br /> Applicant's Signature: , pa�: <br /> ,, , <br /> �'' , � i �� <br /> Last Uodated: 05-04-2009 � ' ' <br />