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Nov 0911 08:OOa Schenkel 9524701781 p.1 <br /> C�ty of 4rono <br /> Building Permit appfica�fon �or Internal VNar�C <br /> � � � (windows, doors, �Fding, re-roof, etc. � . _ � � .�' �� <br /> ) �� <br /> Mailing Address: Permit numb� <br /> 0.��,�. PO Box66 <br /> � O Crystal Bay, M�55323-0066 Date rece�ved; <br /> �,� ,, Sireef Address: Received�by: <br /> ��,� Gtih 2750 Ketley Parkway �Plan reviewfee: <br /> ��o$,� Orono, MN 55356 <br /> Total-Fee: <br /> Il�ai�: 952-249-4600 Fax 952-249-4616 wvvw_ci.orono.�nn.us ' <br /> This application form must be completed in fuil and all required information must be submitted. � <br /> lncomplete appiications will be returned. (Please print) <br /> GEN�RAL INFORMATtON: rL� � <br /> Job Site Address: � �� V��!� ' <br /> Will fihis be a Parade of Homes, Remodelers Showcase Home �r ofher Display Hosne? Yes No <br /> If yes,a special event permrY is required with Po/rae Deparfinent and CTiy Ccuncil appraval 60 days pvior to the evenL Shultle b�s service will be <br /> ►equirad unless applicent demonstrafes s�cient on-site pariong is available. Non-oermitfed events wDf no!be aAowed. <br /> CQNTRACTORI APPLICANT If�fFORMATION: <br /> Name: :�r��t�`tiL- �v�� z�c:— <br /> � State L.icense.# ��;� E��j 3 J Expiration Date: �3 <br /> l.ead Certificatio� Number. Expiration Date: <br /> (far work on homes thaf-were constructed prior fo 1978 <br /> Pho�e: yS,�-- "7 j- %l��S (office) (cell) <br /> Maifing Address: ,�%j 7S� �al`�-�(1 �h1,1�r,L �.� City:_S�v;ti1-Wu� ZiD:•� ..�"333i <br /> Cantact Person: ^ Hppficant is: Cont�acior 1 Homeowner cc���ia o�e► <br /> Emai!and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: J���-►-h .�� ' <br /> Phone(day): � ' . � - - ��'�, <br /> Address: City: ZIP: <br /> Emai!and/or Fax <br /> PROJECT IidFORMATION: <br /> Ty�,,e of Project Qny earti�movement may require <br /> ❑ �oor�s) ❑ Rernodel �]Water Damage MCWD review�permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s} ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding i ❑ Restoration ❑ Other: (specify) Deephaven,MN 55391 <br /> � hone: 952-471-Q590 <br /> �I R�roof ' ��� ❑ Fire Damage Fax: 952�71-0682 <br /> ►�� � ��`� wvv+ti�.minnshahacr�2ek.ara <br /> Overalt Project Descriptiort: <br /> Estimatied Construction Vatuation of P�oject (excluciing land} � 7��� ' <br /> � <br /> APP�lCAN3 ACKNOW�EDGEMENT: <br /> ' • Agrees to provide all information requi�ed or requested by the Building Departmerrt; <br /> i <br /> - • Certiftes ti�at the information supplied is true and comect to the best oP his/her knowfecfge. The applicant recognizes t�at tt�ey <br /> ar�solely responsible for subm�tting a compfete appfication being aware that upon fai�ure to do so,the staff has no altemstive <br /> but to reject it�ntil it is complete; <br /> • 5ome or all of the information that you are asked f.o provide on this appfication is classfied by State law as eitt�er private or <br /> i confidential. Private data is information which generally cannot 5e given to fhe public bu: can be giwen to the subject of the <br /> data. Confidential data is information which generaliy cannot he given to either the public or the subject of the data. Our <br /> purpose and iniended use of thi informati n is to ann Ily update our records and records of other gavemmental agencies <br /> re uired b law. f� ou refuss to I the mtation e a pficafio ma not be issued. <br /> AppiicanYs Signature: Dat�: !��r—1� <br />