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--. City of Orono � <br /> � Building Permit Application for Internal �IVork <br /> � (windows, doofs, siding, re-roof, etc.) � <br /> Malling Address: permit nu�nber. <br /> O�O�O PO Box 66 . <br /> Crystal 9ay, MN 55323-0066 DBte le�ved: <br /> � s. Stnset Address: Reoeived;by: <br /> �,� Gk�' 2750 Kelley Pa�kway Plan revi�w fee: <br /> � 4$ Orono,MN 55356 <br /> Total Feei <br /> AA3in: 952-249-4600 Fax: 952 24a4616 www.ci.orono.mn.us � <br /> 7his applica�on form must be compieted in full and all required informadon m1�st be submitted. <br /> Incomplete applicatlons wfll be ratumed. (Pl�ase print) ; <br /> GENERAL INFORMATION: <br /> Job 3ite Address: [^� �,� �l� <br /> Will this be a Parads of Hcmes Remodelers Showcase Hom or other Display Home? Yes No <br /> 1I yes,e special evenf permit!s�equirsd with Po/ice pepa�tment and Ciry Cound/approvai eo days pnor to th�evenf. Shurtle bus senaoe w�►be <br /> required unless applicant dernonalratea sufficient on-site pa�ldng is availa�/e. Non permiMed eve►tts wU!not be allowed. <br /> CONTRACTOR/APPL CANT INFOR ATION• , � <br /> Name: ��,�,p �,myr,s y, <br /> State license# �p�q.2 � Expiration Qate: 2._. <br /> Lead Certificatlon Number: Expiration C�ate: <br /> (fer wbrk on homes thet weie conslrutE�al prfor io 1978 <br /> Phone: 12 I � (office) (cell) <br /> Mailing Address: �L Y��� � ,, City: ,/ ��►,��.� ziP: 5f 3 3 <br /> Cor�tact Person: ; ;,�ov� Applfcant i • ontracto �/ Homeowner �ctrcie o�� <br /> Email and/or Fax: - � (m / <br /> PROPERTY OWNE FORMAT ON:� , <br /> Name: � <br /> Phone(day): gl�.. '�� (o� <br /> Address: �`j� /�,v�1 L.r•• 'b���e(w C�Y�Drns�v� ZIP: 5-ri�'/ <br /> Email and/or Fax ' <br /> PROJECT INFORMATION: � <br /> Type of Rrojact� Aoy eatth;roovement may require <br /> ❑Door(s) ❑Remodel ❑Wate�Damage MCYV�review i Pe^nils: <br /> Minnehaha Cre�k Wat�r�hed District(MCWD) <br /> Q Window(s) ❑Repair ❑Stortn Damage 18202 MinnetonKa BNd <br /> D Siding ❑ Restoretion ❑Other.(spedy) Deephave�,MN 55391 <br /> Phcine: 952-471-0590 <br /> �Re-roof ❑Fir�e Damage Fax: 952�171-0692 <br /> www.Minnehahac�eek,ora <br /> overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) ; ,�Q,p�T <br /> APPLlCANT ACKNOWLEDC3EMEN?: � <br /> • Agr+ees to provide all infortnadon raquired or reques�ed by the Building Depafinent; � <br /> . Certiflcs that the infortnation supplied is tru�and oorrect to the best of his/her knowledge. The applicant recogniz�s that they <br /> are solely�esponsible fo�submitting a complete application being aware that upon failure to�do so,the staff has no altemative <br /> but to rejed ii unti)it is complete; � <br /> � Some or all of the informatlon that you are asked to provlde on this application is Gasei�ed by State law as either private or <br /> confidential. Private dafa is information which generally pnnot be given to the public but can be given to the subject of the <br /> data. Confideritial data is informatlon which generally cannot be given to either the public or the subjed of the data. Our <br /> purpose and intended use of this informadon is to annually update our reoords and records of other povemmental agencfes <br /> uired b law. If ou refuse u I th 'nformabon,the a lication ma not be issued. ' <br /> AppNcanYs Signature: Date: � ��3/ZO ►� <br /> Last Updated: 09-01-2011 - <br /> Z,z:a6gd 9S9fii6bZZS6��l SZ99£ZS8Z9 :wo-�� 9S�0T ZTOZ-�O-�Jfld <br />