2011-00668 - adv plan review - Laserfiche WebLink

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' � yl � � �1 , / �� City of Orono �� "� Building Permit Appiication for nternal Work �c'q� ! , (windows, doors, siding, re-roof, etc.) Mailing Address: permit number. o?O//-��d�O (o � �g O�� Crystal Bay,MN 55323-0066 Date received: 7-�8� /� a a SY�eet Addiess: Received by: � �, Gti�' 2750 Kelley ParkwaY Plan review fee: Z�. �o�.� Orono,MN 55356 pZ0/(—DD�o 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 submitted. tncomplete applications will be retumed. (P/ease print) GENERAL INFORMATION: Job Site Address: i n f�i � C� �. » 55��S Will this be a Parade of Homes, Remodelers Showca e Home or other Display Home? Yes No !f yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates suficient on-site parlvng is available. Non permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: Qa�JC?r.'1'" /� E�sGi�l State License# Expiration Date: Lead Certificafion Number. Expira6on Date: (for►Mork on homes that were constructed prlor!0 1978 Phone: �S 2—i-1 75'—(,`f 5 2 (office) (cell) Mailing Address: �'y) ;,� � � n [., �� City: o ��V ZIP: �` 3 Contact Person: e Applicant is: Contractor / Homeowner �ci�cie o�e� Email and/or Fax: {�� K rn-I-1��, � A'1 G�1 c�• ��^ PROPERTY OWNER I FORMATION: Name: o�e►�7� d'r�c� I�i'��C��r !��%3�a� Phone(day): q`SZ-y 75�-(4 5 2 Address: �;�79 ,(?1,��r,��tdr,�E-crf�iw�h��hd�a��e ��ri�G`n��o,tm�►/ Z1P: 553� Email and/or Fax � �/�m-�-1�� a vY1 G�i J'1".. C�r» PROJECT INFORMATION: Type of Project: Any earth movement may require MCYYD review b permits: ❑Door(s) �Remodel ❑Water Damage Minnehaha Creek Wa�rshed District(MCWD) ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd �Siding ❑Restoration �Other.(specify) DeePhaven,MN 55391 ` Phone: 952-471-0590 ❑Re-roof ❑Fire Damage �iO,�I� �a�"F Fax: 952-471-0682 �"�,�n r o�' www.minnehahacreek.orq Overall Project Description: • b lE acs E �-'►o�I 4YI�l F r^ e. Estimated Construction Valuation of Project(excluding land) $ jp,�p�j APPLICANT ACKNOWLEDGEMENT: . Agree.s to provide all information reyuir+ed or requested by the Building Deparhment; • Certifies that the information supplied is true and corned to the best of hislher knowledge. The applicarrt recognizes tfiat they are solety responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to reject it urrtil it is complete; • Some or all of the information that you are asked to provide on this application is classfied by State law as either private or confidential. Priva�data is information which generally cannot be given to the public but can be given to the subject of the data. Confiderrtial data is information which c,�:nerally cannot be given to either the public or the subject of the data. Our purpose and irrtended use of this information is to annually update our records and records of other govemmental agencies uired b law. If ou refuse to su the infom�ation the a lication ma not be issued. ` /��.�� ApplicanYs Signature: ,�.Q,r�?`� 6L -��e,•�__ Date: Last Updated: 03-01-2011