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SEP/20/201.1/TUE 12; 08 AM Elder Jones Building FAX No. 952 854 4909 P, 002 <br /> � <br /> City of Orono . <br /> Buitding Permifi Application for Infiernal Work <br /> (windows, doors, sidin , re-roo�, etc.) <br /> MailingAddress: Permit number: �Dl/— �/D$ <br /> 0,�,��� PO Box 66 <br /> Crystal Bay, M N 55323-0066 Date received: -Z�- � ( <br /> ''�r S�-eet Address: Received by: � S <br /> �� 2750 Kelfey Parkv�ray Plan review fee: <br /> ��.�E�o$,1� Orono,MN 55356 ,,�/,�.�.o <br /> Total Fee: �'8 ,�j� �r-�• ��� <br /> Main: 952-2d9-4600 Fex: 952-249-4616 www.ci.orono.mn.Us <br /> This application form must be completed in full and all required information must be submii�ed. <br /> Incomplete applications wi11 be returned. (P/ease print) <br /> G�NERAL INFORMATION:� 8� u Q� �O 4 �(e �l c� (��(1� L on� �� 1�d� <br /> Job Site Address: <br /> Wifl this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> !f yes,a specia/avent permlf is repvired wlth Pollce Department and Clty Couna/approval 60 days prior to the event Shuttle bus aervice wlll be <br /> required urtless app�icant dvmonstrates suflrcient on-slte parking is evailab/e. Non•pennitted evenis w111 nof be allow�ed. <br /> GONTRACTOR/APPLICANT IN�ORMATION: <br /> Name: Jb�[ ED �� /�i/'/�/ <br /> State License#� Pella Windows &Doors S� 8Y 5� �y7 , <br /> Phone: 15300 25th Ave N. Ste 100 (cell) � <br /> Mailing Address: plym.outh,M1�T 55447 Z�P' <br /> Contact Person: Lic#2016�884�h. 763/745-1400 lomeowner �c�ni.o�a� <br /> Email and/or Fax: <br /> PROPERTY OWN�R I ORJIfI�TION: �C� � � C <br /> Name: b •F <br /> Phone(day): '��+� '� f • ��� <br /> Address: ?� _ O __l.�a�!1 D a a/ c�t,,: 6�d n o _ z�P: �'s�g 1 <br /> Email and/or Fax <br /> PROJECT INFORMAT(ON: <br /> Type of PI'Oject: Any earth movement may require <br /> MCWD review 8 pennits <br /> �.Qoor(s) O D Ramodel ❑Nlater Dam2ge <br /> Minnehaha Creek Watershed District(MCWD) <br /> Window(s) � �Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> DeephaVen, MN 55391 <br /> ❑Siding ❑Restoration ❑Other. (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> � Ft�loof ❑ Fire Damage tNvvW.minnehahacreek.Ofc] � <br /> Overall Project Description: /q N o u�" /`t a G A�1 �' � � <br /> Estimated Construction Valuation of Project excludin land S t 7 7 � r1 lJ <br /> /'t�l4!1 /�l� � <br /> APPLICANT ACKNOWL�DGEMENT: <br /> . Agrees to provide all it�formation required or requested by the Building Departmerrt; <br /> • Certifies that the information supplied is true and oorrect to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for�ubmitting a complete application being aware that upon failure to do so, the staff has no ahemative <br /> but to rejeCi it urrtif it is complete; <br /> . Some 0�all of the information that you are asked to provide on this application is classified by State law as e'rther private or <br /> confrderrtial. P�iVate data is irttormation which generally cannot be given to the public but c2n be given to the subject of the <br /> data. CorrFdential data is information Whlch generally cannot be given to either the public or the subject of the data. �ur <br /> purpoae and intended use of this iriformation is to annually upd�te our reoords and records of other govemmental 8gencies <br /> re uired b law. ff ou refuse to su I the infotmation the a IiCdtion ma not be issued. <br /> Applicant's Signature: ' `� Date: ` ��p��� <br /> i��►��„�A,��+- �F_na.�nnq <br />