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APR/23/2012/MON 09; 40 PM FAX No, 952 854 4909 P, 002/003 w � City of Orono Bu�lding Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) Mailing Address: Permit rlumber. o�� D 03Z Z- O.�Q,�,O PO Box 66 Crystal Bay, MN 55323-0066 Date received: L — �Z ' ` y�' ,, Street Add�ess: Received by: �' y 2750 Keliey Parkway Plan feview fee: �� +° Orono, MN 55356 �`�1t�g�o Total Fee; � (>� Z� Main: 952-249-4600 Fax: 952-249-4616 www•cl.orono.mn,.us �,� This application form must be completed in full and all required information must be submitted. . Incomplete applications will be returned. (Please prinr) GEN�RAL INFORMATION: C ,,/ f Job Site Address: v�� 7 � J�Q C� �G� � 0 Q �a Q Wiil this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No /f yes,a speGa!event permif is i epuiretl wlm Pdice Department and C�'ry Counci/approv�60 days prior to the event Shutde bus service wi!/be - iequi�ed uMess applicant damonstrates suf(cient or,�7e parking is avai�ab/e. Non-permitted events w111 not be allowed. CONTRACTOR/APPLICAN7 INFORMATION: Name- State License# �' Pella Nortb�and � e • Phone: 1�300 25th.A,ve N. Ste 100 ' s� ?�►S'•6�! ce11 Mailing Address: PI ou MN$5447 ZIP: Contact Person_ X,ic#B 645090 Ph. 763/745-1400 �omeownsr �c�.�k o�.� Email and/or�ax= PFtOP�RTY OWNER I FORMATION: Name: Q i1 n � S n Phone(day): Sa �/7� ' J Address: ,Z o �✓ Ci : A aT a ZIP: �s.34 / Email and/or Fax PROJEGT INFORMATION: Type of Projsct: Any earth movement may require MCWD review 8�permits G�.Dovr(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershsd Dist�ict(MCWD) ❑Window(s) [�-Repair �]Storm Damage 18202 MinnetOnka Blvd neephavsn, MN 55391 [�Siding ❑ Restoration ❑ Other.(specify) Phone: 952-471-0590 FaX: 952-4�71-0682 ❑R�roof ❑ Fire Damage www.minneh8ha�reek.ora Overall Project Description: t/1 r � /�'l e� /�d Q' J Estimated Construction Valuation of Pro ect ezcluding land $ APPLICANT ACKNOWLEDGEMENT: � • Agrees to provide all information required or requested by the Building Dep�rtment; . Certifies that the ir�fOrmation supplied is true and Correct to the best of his/her knowledge. The applicant recognlZes that they ar6 SOlely responsible fvr 5ubmltting a complete applic�tion being aware that upon failure to do so, ihe staff has no altemetive but to reject ii until It is complete; . Some or all of ihe information that you are asked to provide on this application is class�ed by State law as either private or confidential. Private data is irrformation which genefelly c2nnot be given to the public but can be givsn to the subjeCt of Lhe data. Cor�fdential data is informaUon which generally cannot be given to either the public or the subjeot of ihe data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies re uired b t8w. lf ou refuse to su I Che fnformation,the a lication ma not be issued. ----• S' ��y f l a Applicant's Signature: G— Date: