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I <br /> . ab 4972- :/ <br /> _to.60 <br /> City of Orono <br /> • Building Permit Application for Internal Work <br /> ;(windows, doors, siding, re-roof, etc.) <br /> O MullingPenne number: /0-DOE45 <br /> r�:gt- <br /> Q�\ <br /> Crystal pay,MN 55323.0066 . Data received: i h O <br /> (a Received by: <br /> \� :1 5 kW 4. 27Parkway <br /> r^, �a Kelley Pian reviewfae• <br /> y� Orono,MN 55356 <br /> Totes Fee: * / 3 fi.te34 <br /> Main: 952-240.4800; 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: M �+ <br /> Job Site Address: /4t CH (. <br /> Will this be a Parade of Homes, Remodelers Showcase Ho or other Display Home? 0 Yes No <br /> It yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event Shuttle bus service be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be alfaowed. <br /> CONTRACTOR/APPUCANT 1111 DRMATION: <br /> Name: Man • C.QQt�S r(A+lon <br /> State License# 1 • ., , Expiration Date: <br /> Phone: , •— ' , j�r . (office) ce <br /> Mailing Address: , , t ' di* b ski- CIN:Own)!t ZIP: SS 7 4ll) <br /> '7 <br /> Contact Person: t t • it mO Ono <br /> Applicant is:)(Contractor / Homeowner (Weis on <br /> Email and/or Fax: �) 1-w_5' 15 <br /> PROPERTY OWNE; INF•RMATION: <br /> Name: A•_A4• Il 5 <br /> Phone(day): 'PtITit . , <br /> Address: -_- <br /> i(),• 6 . Li Pel City: r zatot.. ZIP: 5531 I <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> 1:1 Door(s) ID RemodelMCWD review 8 permits <br /> 0 Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> o Window(s) ❑RePsir 0 Storm Damage 18202 Minnetonka Blvd <br /> 553 <br /> ❑Siding ❑Restoration 1:1 Other(specfy) DPhhone::952-471-0590 <br /> �e,( Fax: 952-471-0682 <br /> Re-roof 0 Fire Damage www.minnehahacreek.era <br /> Overall Project Description: ;'flJb 1 rt. p.nM <br /> Estimated Construction Valuation of Prat (excluding I ) $ .../700 0 .o° <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 taster knowledge. The applicant recognizes that they <br /> are 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 all of the infor matibn that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information',Mob 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 /> =eked by law. if You refuse to the ,. _y: ,the appllcatlon may not be Issued. <br /> 0/ <br /> Applicant's Signature: Date: , q, ,61 <br /> • <br /> Last Updated: 05-04-2009 <br />