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� � � -� <br /> C�ty of Orono (���,t��,�.4� � � � 7� <br /> � Building Permit Application for I�nternal Work c� <br /> (windows, doors, siding, re-roof, etc.) <br /> --� Mailing Address: Permit number: 0�0/�—Ob!o (o <br /> O��,�.0 PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: 7—��' �� <br /> a � ��� s. Stneet Address: Received by: � <br /> �',�, � �%� G�`s' 2750 Kelley Parlcway Pfan review fee: �..�, <br /> '�flg��o8� Orono,MN 55356 a0/�—QQ� <br /> "-- Total Fee: <br /> Main: 952-249-4600 Fax: 952-249�616 www.ci orono.mn us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: l7�� n�, �rr fc� /-�,c' � :� (._.cU> > »G 5S3 5 <br /> Will this be a Parade of Homes, Remodelers Showca e Home or other Display Home? Yes No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> requrred unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �c:�)�i^t � E(�c�� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: c:� S Z -i� 7�' _(� �Z (office) (cell) <br /> Mailing Address: �� �,� F . � ,� [, n�� City: •��,,;G rl��J ZIP: �� � � , <br /> Contact Person: e ` - �. ` Applicant is: Contractor / Homeowner �ci�ie o�e� <br /> Email and/or Fax: _ }�n I K vn�f"�SY_ a� M G�] S i• C-�•f^ <br /> PROPERTY OWNER INFORMATION: <br /> Name: �d�j rt�,7` cr_�l� �f°G�'y /�c�/ �'c:l'� <br /> Phone(day): �_SZ—y 75-(c{5 Z <br /> Address: �: 7�/ {�11'��u�Etc��KcYl�fic��l�t��ld�,c��9r. CitY�C.�Y��1C��Yl� ZIP: 5�,3� <br /> Emai l an d/or Fax _� !/�m �-l�d �' vi�1 e.�l .3'i.� CO�rr <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review�pertnits: <br /> ❑Door(s) �Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> �Siding ❑Restoration �Other:(specify) Deephaven,MN 55391 <br /> ,�1 Phone: 952�71-0590 <br /> ❑R�roof ❑Fire Damage ��J��� `fv� � Fax: 952-471-0682 <br /> �'�-�r� _�•��� www.minnehahacreek ora <br /> Overall Project Description: .>r V lE �c - C -��s-ic�� c�rJc1 � �►^- � <br /> Estimated Construction Valuation of Project(excluding land) $ jd,���j <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Departrnent; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su 1 the information,the a lication ma not be issued. <br /> ApplicanYs Signature: ��• �,�7`� � '%�__ Date: 7//�//� <br /> T <br /> Last Updated: 03-01-2011 <br />