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� � City of Orono Building Perr�it Application for Internal Work (windows, doors, siding, re-roof, etc.) _ - Mailing Address: Permit number. �� 1►,, PO Box 66 � .�o, O O�� Crystal Bay, MN 55323-0066 Date received: � �� Received by: �U� 2B 2�� „,� �;, r y' ,; �,� Street Address: — ��'� ��}.�� r U ti j 2750 Kelley Parkway Plan review fee: � � ��, 'I��'�`��O% Orono, MN 55356 t �1i�v��• w, , :. .��si3o�" , � Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us _ Tl�is application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: � 7 U 5.,, s � a �,f w � � „j � b �j / Job Site Address: v Q ---- - Will this be a Parade of Homes, Remodelers Showcase ome or other Display Home? ❑ Yes ❑ No If yes, a special evenl permit is required with Police Department and City Council approval 60 days prior to the evenL Shultle 6us service will be reryuired unless applicant demonstrafes sufficient on-site parking is available. Non-permil(ed events will nol be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: - ---- State License# Pella Nortllland Phone: 15300 25th Ave N. Ste 100 _ (cell) Mailing Address: Plytnouth, MN 55447 ZIP: Contact Person: Lic# BC645090 Ph. 763/745-1400 ��meowner (Circle Onc) Email and/or Fax: — PROPERTY OWNER IN OR ATIONL• Name: �C � 4 /� �C ` � - --- Phone da �-- Q Address: y)� a '] v Syu 5 4�R � W VD� /� � City: �.1'(t �S/b!� ZIP: 'J�s 33 / Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review& permits ❑ Coor(sj ❑ I:emodel ❑ Water Damag� Minnehaha Creek Watershed District(MCWD) �Window(s) ❑ Repair ❑ Storm Damage 18202 Minnelonka Blvd Deephaven, MN 55391 ❑ Siding ❑ Restoration ❑ Other. (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑ Re-roof ❑ Fire Damage www minneh�hacre�k.orq Overall Project Description: � (� („��/� rt G �,! M� n Estimated Construction Valuation of Project (excludin land) $ / 8 / 6 9 APPLICANT ACKNOWLEDGEMENT: —_ . Agrees to provide all information required or requested by the Building Department; —� • Certifies ihat the information supplied is true and correct to the best of his/her knowledge. The applicant recoynizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; . Some or all of the information that you are asked to provide on this application is classified by Siate law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies re uired by law If you refuse to supply the information the application may not be issued. �� Date: ` ` � �� ApplicanYs Signature: _ — Lasl Updated: 05-04-2009