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� ` ' City of Orono Buiiding Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: � –�c� �,�,� PO Box 66 _— Q , Q ` Crystal Bay, MN 55323-0066 Date received: �. } a a t Str�et Address: Received by: �� �'�A �' �ti`�' � 2750 Kelley Parlcway Pian review fee: �sgESKog� Orono, MN 55356 — Total Fee: ��/„ �n� Main: 952-249-4600 Fax: 952-249-4616 wtivuv.ci.orono.mn.us Y�� Y This application form must be completed in full and all required information must be submitted. Incomplete applications wril!be retumed. (P/ease print) GENERAL INFORMATION: JobSiteAddress: 659 Minnetonka Highlands Lane Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No If yes,a special event pennit is required wdh Police Depa+iment and City Coundl approva/60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufl5cient on-site parking is available. Non-peimrtted events will not be aUowed. CONTRACTOR/APPLICANT INFORMATION: Name: J Z a c I n c . State License# 2 0 5 9 3 8 4 5 Expiration Date: 3-31-2 012 Lead Certification Number: NAT lObl96-1 Expiration Date: 3-16-2012 (fnr work on homes that wene constructed prior to 1978 Phone: (763) 497-4444 (office} Jerrys- ( 763) 238-4051 (cell) MailingAddress: 5249 Ogren Avenue NE C�tY�St.Michael Z�P�55376 Contact Person: J e r r v Z a c h m a n Applicant is: Contractor / Homeowner �circ�o�� Email and/orFax: i errv i zacinc . com Fax - (763) 497-4454 PROPERTY OWNER INFORMATION: Name: Richard Speeter Phone(day): (612) 3 3 9-7 5 6 6 Address: 659 Minnetonka Highlands Ln City:Orono ZIP:55356-9728 Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑Door(s) ❑ Remodel ❑Water Damage MCWD review S permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair [�]Storm Damage 18202 Minnetonka Blvd ❑Siding ❑Restoration ❑Other:(specify} Deephaven,MN 55391 Phone: 952-�71-0590 (� Re-roof ❑Fire Damage Fax: 952-471-0682 v�•,nv.minnehahacreek.ora Overall Project Description: R e p a i r S t o r m D a m a g e Estimated Construction Valuation of Project{excluding land) S D /sa APPLtCANT ACKNOWLEDGEMENT: • Agrees to provide a11 infoRnation required or requested by the Building Departme�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€ailune 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 gerterally cannot be given to the public but can be given to the subjed 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 intendeti use of this information is to annually update our records and records of other govemmental agencies re uired b law. If ou refu e t su I the information,the a lication ma not be issued. Applicant's Signature: � Date: �� G '�� Last Updated: 03-01-2011