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1i3�/19/�1011/TUE 08: 57 AM Fax Server FAX No, - P. 001/001 ` � � `r IV . . �� '�/ City of Orono ` Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: permd number �. -� �O � . O�,�.j�O PO Box 66 m Crystal Bay,MN 55323-0066 DBte:receiveii `� . L. � s, St�eet Address: Received by: ��`� 2750 Kelley Parkway Plan review fee ��o�,*� Orono,MN 55356 ; Total Fee: , ` ��i�;/ � , 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. Incomplete appllcations will be returned. (Please prinf) GENERAL INFORMATION: Job Site Address: �j(p� ��(�— (w- (..c►an� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o !f yes,a speclal event permlt!s requlred wlth Pollce Depariment and CJty Counci!epproval 80 days prior to the event. Shuttle bus service will be requlred unless appllcant demonstretes sufl7clent on-site parking is available. Non-permltted events wA!not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: T o/ ,., ✓bc� o/ ,/' State License# ZOI"1 TO'1`� Expiration Date: 3 $1 I� Lead CerGfication Number: Expiration Date: (for work on home�that were constructed prlor to 1978 �" Phone: - )�' $Qj�� ZOO� (office) W�Z � ZZ� - �-{�p (cell) Mailing Address: Z 3 '� City: (��pN v ZIP: 553(o Contact Person: �W G Applicant is: ac o / Homeowner �c�r�i•o�o� Emaii and/or Fax: 5Z- �/3�. cfp p� PROPERTY OWNER INFORMATION: Name: Phone(day): Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Projoct: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review 8�permits: Minnehaha Creek Watershed 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 Fax: 952-471-0682 www.mi nnehahacreek.orca Overall Project Description: Estimated Construction Valuation of Project(exciuding land) $ �Z,, OPJ� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifles that the information supplied is Vue and correct to the best of hislher knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provfde on thls applicaUon is classlfled by State law as efther prfvate or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confld�tial data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies re uired b law. If ou refus o su I he information the a lication ma not be issued. Applicant's Signature: G� Date: � /� �� i��r i i�Ar�• nz.man��