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City of Orono <br /> l �� V • Building Pe�mit Application for Internal <br /> Work <br /> (windows, doors, sidin , re-rcof, etc. <br /> Mailing Add�ss; <br /> O�"�^�' PO 800c 66 Permit number: 021�//-�73� <br /> � Crystal Bay, MN 55323-0066 Date received: a 7/ <br /> ''� � '� St�et Address: Received by: <br /> � V o~� 2750 Kelley Parkway <br /> �sao�'f°' �rono, MN 5535B Plan review fee• <br /> Main: 952-248-4600 Fax: 952-249-4616 www,ci.orono�*+�„a Tatal Fee: �r�j��� <br /> j�. <br /> This application forrn must be completed in full and all required information must be submitted. <br /> Incomplete applicatlons will be reivrr�ed, (p�eBse prinf) <br /> GENERAL INFORMATION: <br /> Job Site Address: o���j� ��0.d �j�� �00� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes <br /> Kyes, a specla!ev�snt permlt is riequir�d with Polica pepeynent and City Council approva/60 days prior to Ghs event. Shuttte bus service will be O <br /> requiied un/ess epp/lcenf demonstret�s sulf"icient on-site parking is evailab/e. Non-permitted events wi!!not be aUowed. <br /> CONTRACTOR/APpLICANT INFORMATION: <br /> Name: Renewa] By Andersen <br /> State License# <br /> Phone: �-- 1920 County Road "C" West E�cpiration Date: <br /> Mailing Address: Roseville, MN 55113 ��� <br /> Contact Person: License #20130983 C��� ZIP• <br /> Email and/or Fax: - 651-264-477� �t is: Contractor / Homeowner (ClrCle One) <br /> -- <br /> PROPERTY OWNER INFORMATION: <br /> Name: ,��� ���� <br /> Phone(day): ' + ��b� <br /> Address: 5� <br /> Email and/or Fax C� � Z�p; <br /> PROJECT INFORMATION: <br /> TYPe af Project: <br /> Any eartfi movement may requlre <br /> ❑Ooor(s) ❑ Remodel MC1ND review�permits <br /> ❑Water Damage <br /> Window(s) ❑Repair Minnehaha Cresk Watershed Oistrict (MCWD) <br /> ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑Restoration Deephaven,MN 5539'I <br /> ❑Other: (specify) Phone: 952-477-0590 <br /> ❑ Re-r�pF ❑ Fire Damage Fax; 952-471-06g2 <br /> Overall Project Descrlption: � �a�v.minnehahac.r�ek ora <br /> Estimated Conatruction Valuation of Pro ect(excluding Ia d1�� $ S� � ` <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> � Certifies thal the information supplied is true and correct to the best of his/he� knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete applicatian being aware that upon failure to do so, the stafF has no alternative <br /> but to reject it until it is complete; <br /> • 5ome or all of the information that you are asked to provide on ihls application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given io 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 annuaHy update our records and records of ather governmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: � `,A �rn��,�� �d� � <br /> Date: p� -� 1 <br /> Lasf Updated: 05-D4-2009 <br /> Z 'd 06T9trG9TS9 3�II1213S 1IW213d Q B S �I 9S =B TTOZ LZ i�C <br />