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Sep 30 11 11:21a Schenkel 9524701781 p.3 City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number c40//— d// 9' COQ Cr Box 66 9Z30/// r O Crystal Bay, MN 55323-0066 Date received: C, T I Street Address: Recehied-by. �a ��t ';, 2750 Kelley Parkway Plan review fee: lfit-X- . ''�' ' MN 55356 .._ ) Orono, Total Fee: /1/0,?0,,&) Main: 952-249-480 Fax 952-249-4616 www.ci.orono.mp.us This application f rm must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: .3- - 0 i_l IS C 6tr Job Site Address: (� Will this be h Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes 0 No 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 required unless appricant demonstrates sufficient on-site parlang is available. Non-pennitted events will not be allowed. CONTRACTOR!APPLICANT INFORMATION: Name: '..11-el i me_ E-,n-74-rr r'‘s ISS --rL e State License# ad/ 6'6,c 3) Expiration Date: /3 Lead Certification Number. Ai i4-r //t;/yO—/ Expiration Date: 7-1K (for work on homes that were constructed prior to 1978 Phone: Ica 917f`1d j (office) (cell) Mailing Address: a‘-,--7.5-- 2,,,i-t4, g)v elf ift.a City: S ‘24l&k t ZIP: ,,4 r✓s'-33/ Contact Person: g‘ZJ Applicant is: o tractor / Homeowner tarda One) Email and/or Fax: %,Sa_ �17d — /70/ , PROPERTY OWNER iNFORM ►TIgN: Name: A/► t,nn, Kil ze- Phone(day): Address: 3,3.5 Q 1 C. C(' l,s ,( bel City. ZIP: Email and/or Fax r PROJECT INFORMATION: Type of Project Any earth movement may require ❑ Door(s) 0 Remadel 0 Water Damage MCWD review&omits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) 0 Repair 0 Storm Damage 18202 Minnetonka Blvd hone: ❑Siding ❑ Restoration 0 Other.(specify) Pven, MN 55381 Phone: 952-471-0590 `gRe-roof 0 Fire Damage Fax 952-471-0682 www.min n e hahacreek.orq Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ YAZI C) APPLICANT ACKNOWLEDGEMENT: . • Agrees to provide all information required or requested by the Building Department; • • Certifies that the information supplied is true and correct to the best of his/her 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 provide on this application is classified by State law as either private or confidential. Private data fa information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is infomration which generally cannot be given to either the public or the subject of the data. Our purpose and intended use f this In on is o annually date our records and records of other governmental agencies required by law. If you refu to sup the i 'on,thea licence ay not be issued. Applicant's Signature: I Date: 7 .7<-,,_ ( Last Updated: 03-01-2011