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, . . <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> windows, doors, s�din , re-roof, etc.) <br /> MailingAddress: pertnitnumber: • <br /> ��,,.- <br /> Og�O.I�o Po s�ss . <br /> Cryst�l 6�y, MN 56323-0066 p����; <br /> � SOneefAtldress: Received by: :' <br /> b►� 2750 Kelley Parkwsy Rlan reviow�fee: <br /> �� prono,MN 55356 , . '� � <br /> Total Fee'. ��� � . , <br /> Main: 952 249-0600 Fax: 952-249�616 www.ci.orono.mn.us •� : , <br /> This application form musE be completed in full and all required information must be submitted. <br /> Incamplete appllcation�will be returned. (P/ease p�rrt) . <br /> QENERAL INFORMA710N: <br /> Job 3ite Address: ^J(� `,,,.,Q, • <br /> � Will this be a Parade of Homes,Remodelers Showcase Home or other Dispiay Home? Yea No <br /> �ff yes.a speaal ever�t psrmlt!s requlred wQh Police Department and Cily Council approval 80 days prior to the event Shr�ltls bus aeiv/ce w�be <br /> requ!►eal unksc applir.ent demonabstes aut�er►t or►,sRe parking is availebfe. Norr-perrn/tted events wal not be adowe0. <br /> CONTRACTOR/ PLI ANT INROItMATI ; <br /> Nsme: � �, 1 <br /> State License# l�"'� p Expiration Date: (3 <br /> Lead Certiftration Number. h(A T- t O�n�o Q- 1 Expiration Date: � <br /> (forwork on homea thatwrere co»swctedpr�o►!o 1978 <br /> Phone: �I�o �-� �SSI _ �O (office) l0 I a,- � - l y(q� (cell) <br /> Mailing Address: a ! C�ty: ZIP: <br /> � Contact Person: ' m S�'��J�.nCS ' Applicsnt is: ontfact / Hortteowher �c��a onq <br /> Email and/or Fax: _� � <br /> PROPERTY OVYNER INFORMATION: <br /> Name: __�• ASaM C,►► � <br /> Phone(dey): ��a� c� <br /> Addres3: City: 21P: �rj� <br /> Email and/or Fax • . <br /> PROJECT INFORMA710N: <br /> �°'� je�� Any earth movemerrt may r+equlre <br /> �Ooor(s) ❑Remodel ❑water Damage ��re���Permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> �INirtdow(s) �Repair ❑Stvrm Damage 1e202 Mlnnetonka Blvd <br /> ❑Siding ❑ Restoration ❑Other:(specify) Deephaven, MN 55391 <br /> 0 Re{oof ❑Fite Damage PF�ce:952�7110-0�590 <br /> www.minnehah�Gfeek Oro <br /> Overe�ll Project Desc�ption: � S �j�p � ���� � � <br /> Estimated Constn,ctioe Valuatjon of Project(excluding I�nd) s • C"- �- J-S �"'�'�"��$ <br /> APPLICANT ACKNOWLEDQEMENT: <br /> • Agrees to piovide all informatlon required or reques�d by the Building Departrnent; <br /> • Cer�fies that the inf�rmatlon supplied is vue and correct to the best of his/her knowledge. The applicant recogn¢es that they <br /> are solely responsible for submiaing a complete application being aware that upon faiture to do so, the staff has no altema�ve <br /> but to reject it ur�il3t is complete; <br /> . • Some or all of the information that you are asked to provide on this application is dassified by State law as elther privste or <br /> confidential. Private data fa information whieh generalty cannot be given to the publie but pn be gNen to the subjsct of the <br /> data. Confidential data is information which generally esnnot be given to either the public or the subject af the data. Our <br /> purpose and irnended use ot this infoRnation is to annually update our records and recards of other govemmental egencies <br /> uired law. If ou� se to su I the informa�on the a lication ma no�bo iasued. <br /> Applicant's Signature: , � Oate: q �� �� <br /> Lest Updated; 0&01-2D11 � <br />