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05/1,12011 15: 33 7634281873 PALPIER WEST CONSTRUO PAGE 02 <br /> City of Orono `' r�3`� <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Malling Address; Permit number: -Q�3 <br /> r Box 66 <br /> o� Crystal Bay, MN 55323-0066 Date received: <br /> O C <br /> O Street Address: Received by: <br /> mR 2750 Kelley Parkway Plan review fee: �`7 <br /> X" <br /> F Orono, MN 55356 <br /> Total Fee: / <br /> Main; 952-249600 Fax: 952-249-4616 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: (v BS (-)I J Crli 5 k•t -8 04 <br /> Will this be a Parade of Homes, Remodelers Showcase 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 pfor to the event, Shuttle bus s rvice will be <br /> requirad unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: p't,kft w t. e,sk (o.,s <br /> State License# 1) A Expiration Date: <br /> Lead Certification Number: fl L4 Expiration Date: <br /> (for work on homes that were constructed prior to 9978 <br /> Phone: -7 t,3 - LAI 6 - I$ It (office) G l Z - 3 3 q 'S S 8 a- (cell) <br /> Mailing Address 14S 4-S si is R ,�P City: ,R,:" "5 riot^_ ZIP: 5S 37y <br /> Contact Person: -7-1 Applicant is: Contra or ! Homeowner (ClrcleOne) <br /> Email and/or Fax: �@_A al n�• �.s ask• rt e,-�- <br /> PROPERTY OWNER INFORMATION: <br /> Name: Dron,o FLO,\-C_ 5��9�1s <br /> Phone(day): R5 z - 4 41 - SLIoa <br /> Address: (005 pfd G�sk,l antis City:L'►7 .�" zlp: 5S35� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑ Restoration El Other: P <br /> (specify) hone!v952 <br /> 47 55391 <br /> Phone: 971-059D <br /> Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.m i n oph aah acreek.c ro <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ 3!s Le, I D <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all information required or requested by the Building Department; <br /> Certifies that the information supplied Is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> aria 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 ail of the Information that you are asked to provide on this application is classified Dy State law as eithor 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 /> required by law. If you rqfu-%Ve to Suppl the infarmation the application may not be Issued. <br /> Applicant's Signature: pate: <br /> Last Updated, 03-01.2011 <br />