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Sep, 1. 2011 4; 38PM No, 7944 P. 2 � . - City of Orono Building Permit Application for Interna! Work (windows, doors, siding, re-roof, etc. g,�,� Ma/',PO Box 66� Permit number. � — �� O O Crystal Bay, MN 55323-0066 �ate received: � � / Street Address: Received by:• � 2750 Kelley Parlcway Plan review fee: �� . �� Orono,MN 55356 �A�� . . � 3� , 3 ai Total Fee: Main: 952-248-4600 Fax: 952-249-4616 www.a.orono.mn.us This application fonn must be completed in full and all required information must be submitted. . lncompl�te applications will be retutned. (Please print) GENERAL INFORMA710N: Job Site Address: �� '�.s�� •�-e-- ��v- • , � � Will this be a Parade of Homes, Remodelers Showcase Home or other Dispfay Home? Yes o Il yrs,a special event permit is required with Police Departmenf and Clry Counal spprova160 days p►ror to the eve»t. Shaltle bus service will De required uMess applicant demonstrates sul�ient on-sire parlang is available. Nony�e►mifted evenes wld not be allowed. CONTRACTOR 1 APPUCANT INFO T10N: Name: ScJ�.+�'4:.r 5 State License# _:zo,�3 r�3 lo ti „_ Expiration Date: .3 0 �. Phane: �Sa-� 7 7- /6 O U office � (cell) Mailing Address: �r�,��s� � �� ( C' '�h S ZIP:S�3 S/ �, Contact Person: �y-f� �,,,�;c I�: Applicant is: ontra / Homeowne� iciru.oe�� Email and/or Fax: _ PROPERTY OWNER INFORMATION: � Name: m L.Ca �_w,_ Phone(day): - 1-- . � Address: a C� Y'V n �� . �n � Ci : �ct��.:�:� • ZIP: .�S� Email and/or Fax PROJEGT INFORAAATION: Type of Project Any earth movement may requlre MCWD review 8 pertnits �oo�(s) ❑Remodel ❑Water Damage Minnehaha Creek Watershed Dlstrict(MCWD) Q Window(s) ❑ Repair ❑Stortn Damage 18202 Minnetonka Bivd Deephaven,MN 55391 ❑Siding ❑Restoration p Other.(specity) Phone: 952�71-0590 Fax 952-471-0682 ❑Re-roof ❑ Fire Damage www.minnehahacreek.orq Overall ProJect DescNpdon: _, „_ Estlmated Construction Valuation of Pro ect excluding land S � � APPLICANT ACKNOWLEDGEMENT: _ . Agrees to provide all i�formadon required or requested by the 8uilding Department; • CertiFes that the infonnatien supplied is true and correct to the best of hisfier knowledge. 7he applicar��cognizes that they are solely responsible for submitting a complete application being aware thet up�n fallure to do so,the staff has no altemative but to rejeCt it unal it is complete; • Some or all of the inforrnation that you are asked to provide on this application is �1ass'rf'ied by Stste Isw es either private or confidential. Private dab is infortnation which genecally cannot be given to the publio but Can be given to the subjed of the data. Confidential data is information which generelly cannot be given to either the public or the subject of the data. Our purpose and intended use of this infortnation is to annuslly update our records and records of other govemmental agencies re uired b law, If ou refuse to su I the information,the a lication ma not be issued. ApplicanYs Signature: �Cy,�� l'1 L Date: C1 ' 3��