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Nov 02 09 11:53a CAPSTONE BROS 9528828885 p.2 <br /> r <br /> City of Orono <br /> i Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. <br /> 0.�, s Cr Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> ,s Received by: <br /> A <br /> Street Address: <br /> \ '��J',i s 2750 Kelley Parkway Plan review fee: <br /> •V Orono,MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 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 /> GEN - L INFORMATION: ` <br /> Job Site 'ddress: �j�-5 0 r61 o rd FOtr' -- 9_a . <br /> Will this i e a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 Yes No <br /> 'f yes, = •ec/al event permit is required with Police Department and City Council approval 60 days prior to the event, Shuttle bus service will be <br /> requited unless applicant demonstrates sufficient on-ale parking is available. Non-permitted events will not be allowed. <br /> CONTRA TOR l APPLICANT INFORMATION: <br /> Name: Ccs ,-toric n{os. COn\- ac\-71m ITn.0. <br /> State U - se U 70 vOcl Q tril- Expiration Date: 3--20[- 2-010 <br /> Phone: q5a- 8•'D.- 8: '8 (office) -i91a--564,- L4.1 13 (cell) <br /> Mailing A, •ress: . to . ' ",v ' 'cl•. CI rat. Ci : ?aA a S -MR- ZIP: ��j3'� <br /> Cor tact - rson: AMMER - * Applicant is: • ' -ctor / Homeowner (throe) <br /> Ell an• or Fax: coo( #- Q J-D- - 8'8 7-- 8 2 g <br /> PR9PE- OWNER INFORMAT ON: <br /> Na e: ondy We e ..sk-rcknd <br /> Ph (d-,): g-- , - O (0S <br /> Ad P�,�-5 0 r actor- Bark- Col City: 0Y-0,1'10 ZIP: 55 551=. <br /> E il an• or Fax <br /> PRQJE a INFORMATION: <br /> Ty p li of • •Ject Any earth movement may require <br /> MCWD review&permits <br /> ❑ or(s) 0 Remodel 0 Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ o s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑ ding 0 Restoration 0 Other. (specify) Phone: 952-471-0590 <br /> ` Fax 952-471-0682 <br /> ww <br /> 'r1`ICf ro•' ❑Fire Damage w.minnehahacreek.oro <br /> Ov II • • ectDescription: 'Tea r 0-4 And R.- fcoc• V1ou�e.. o. AC.roi$2. <br /> i <br /> a Construction Valuation of Project(excluding land) $ 11 i tJ 9 tr. 00 V <br /> APRLIC • T ACKNOWLEDGEMENT: <br /> T -=s to provide all information required or requested by the Building Department; <br /> ' - iles that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> k a solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> b to reject it until it is complete; <br /> • e or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> -• 'dental. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> d, =. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> p ,••.,= and intended use of this information is to annually update our records and records of other governmental agencies <br /> _. ired by law. If you refuse to supply the information,the application may not be issued. <br /> � �1 <br /> App nt' Signature: Date: \1� d_ 0 <br /> Last ... =' 05-04-2008 <br />