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a r City of Orono . ' ` Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: O/ ,. Ov 0 j� PO Box 66 Permit number p o Crystal Bay, MN 55323 0066Date received: f 11_"':'--: E t, street Address: Received by: N:'ilit ( ) Gti`� 2750 Kelley ParkwayPlan review fee:Hog� Orono, MN 55356 -� �k Total Fee: •d ` e - Main: 952-249-4600 Fax 952-249-4616 www.ci.orono.mn.us p - i 3� This application form m st be completed in full and all required information must be submitted. Incoplete applications will be returned. (Please print) GENERAL INFORMATION 5 id �' Rd Job Site Address: Will this be a Parade of Homes,Re odelers Shona e Home or nth r Display Home? ❑Yes akItsio If yes,a special event permit is required wl Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant de nstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/A PLICANT INFORMATION: Name: WV, State License# O3'I 4" ,0 T Expiration Date: 3 Lead Certification Number: '(p,, _I Expiration Date: a -�! (for work on homes�that were constructed prior 1978 I Phone: W Id-Q-7(4 j((6 (office) (cell) Mailing Address: (p�jb nne i ti Ave, City: C, ZIP:E64010 Contact Person: -FIT sc Applicant is: (Lontrac o / Homeowner (circle one) Email and/or Fax: — PROPERTY OWNERINFORMATION: Name: f r-e415511, +- ' nme Phone(day): 15?_ -$f(p Address: 4-3 "' JS a ryazj City: f 6 ZIP:5S3 (p Email and/or Fax `" J ''""""JJ PROJECT INFORMATION: Type of Project: Any earth movement may require 4Door(s) 0 Remodel 0 Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) 0 Repair 0 Storm Damage 18202 Minnetonka Blvd Deepha❑Siding 0 Restoration 0 Other:(specify) Phone:v95,MN -0555 91 0 Re-roof1iO_ /, Phone: 952-471-0590 0 Fire Damage e la� Fax: 952-471-0682 www.minnehahacreek.orq Overall Project Description: k-ptaa 90.6 §..-fib doh Estimated Construction Valuation of Project(excludihg land) $ I 5 36'x ` APPLICANT ACKNOWLEDGEME T: Agrees to provide all information re uired or requested by the Building Department; . Certifies that the information suppli d is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submittin 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 is inform tion which generally cannot be given to the public but can be given to the subject of the data. Confidential data is informa ion which generally cannot be given to either the public or the subject of the data. Our purpose and intended use o •is itformation - to annually update our records and records of other governmental agencies re•uired b law. If ou refus- to su•.I.a.: i-fo ation,the a•.lication ma not be issued. mmla IL Applicant's Signature: 110.4B1/141d04. .. Date: 1 _. I Last Updated: 03-01-2011