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Ju1, 20. 2011 8; 56AM 1634938980 MN EXTERIORS INC. No, 1932 P, �/2 <br /> , <br /> -f <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, sidin , re-roof, etc. <br /> Q'O� MeilinPgo 6ox 66 • Pe��t number: O�D - 8' <br /> Y <br /> Q Q Crystal Bay,MN b6323-0066 Date received: 7 ,Z,D <br /> � StreetAddress: Received by: (� <br /> �t �� 2750 Kelley Parkway Plan review fee <br /> dg �g Orono,MN 55356 <br /> Total Fee: � 3 �, � <br /> Main: 952-249-4600 �ax: 952-248-+3616 . '.o o. <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �} <br /> Will thls be a Parade of Homes,Remodelers Showca�e Home or vther Dlsplay Home? Yes No <br /> If yes,a spaclel event permit is required wT�h Police bepadment end City Couqcil approval 60 days pnor to the event, Shultle bua service wiU be <br /> ►equired unless epplica�demonsfrdfes suillcient on-sile parking/s availQ6le. Non-perrru?ted e�rents will not be allowed. <br /> CONTRAC70R/APpLiCANT INFORMATION: <br /> Name: MI n R�� �12lO(�,�"TA.0 . <br /> State License# �Z� Expiration Date: _ 3-31�O�� <br /> �ead Certification Number: �xpiration Dafie; <br /> (for work on homes thaE xrere constructed prior to 1978 <br /> Phone: -���-$�lj U (office) (cell) <br /> Mailing Address: City: Z�p� ' ` <br /> Contact Person: <br /> Email and/or Fax: �s�� ��� � ` Applicant is: Contractor / Homeowner �c�►��o�e� <br /> c!� �' v�:� m+� , o ,-� _ � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �o�N K�.�"Tbi�D �A<<.l� � <br /> Phone(day): 5a_ s'(�--�� � ' • ' <br /> Address: � S"�lA�F3S �-�( QU Arl� City: LG1J6�(.g�(�' ZIP• S��Zo <br /> Email and/or Fax ' <br /> PROJEC7 INFORMATION: <br /> Type of Project: Any earth movamerrt may require <br /> ❑Door(s) ❑Remodel ❑Water Damage �GWD review 8�permits: <br /> '�Window(s) ❑Repair []Storm Damage Minnehaha 8202 Minneetonka Bllvd��MCWD) <br /> ❑Siding ❑Resto'ration [�Other:(specify) Deephaven,MN 55391 <br /> '�[Re-roof Phone: 952-471-0590 <br /> ❑Fire Damage Fax; 952-471•0662 <br /> h e <br /> Overall Project Descri tion: � � S �N � <br /> Estlmated Construction Valuation of Project(excluding land) $ _�p p ,a o r <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees t�provide all ir�formation required or requested by the Buildin�Department; <br /> • Certifles that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes thst they <br /> are solely responsibls�or submimng a complete application being awere that upon failure to do so,the staff has no altemative <br /> but to reject ifi until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confldential. Private data is inforrnatlon which generally cannot be given to the publie but can be given to the subject of the <br /> date, Contidential data is information which generally cannot be siven to elther the public or the subject of the data. Our <br /> purpose and intended uae of this information is to annually update our records and reco�ds oF other governmental agencies <br /> re uired b law. If u refi,se to su I the information the a lication ma not be issued. <br /> Applicant's Signature: Date: ��e�C.�—a(j � � <br /> Last Updated 03-01-2011 <br />