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,NOV-1-2010 06:42 FROM:ESTHERS PERMITS 6513300894 TO:9522494616 P.2/2 City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc. Malling Addross. _ O.¢, PO Box 66,�O Permit number: Crystal Bay,MN 55323.0066 Date received: Street Address. Received by: — 2750 Kelley Parkway Plan review fee: �k ,a— Orono,MN 55356 -�_..-s ��• Main: 952-240-4600 Fax: 952-249-4616 www.ci.oronmmn.us Total Fee: This application form must be completed in full and all required Information must be submittod. Incomplete applications will be returnod. (Please print) GENERAL INFORMATION: Job Site Address: 4490 Tonkaview Lane Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No Jr yns,a spee/al event permit/s required with POW Department and City Cound/approval 60 days prior to the avant Shuttlo buc sarvlce will be requlrod unloss appilcent demonstrates SlOicient onsite parking is Available. Non-permitted events will not be allowed. CONTRACTOR I APPLICANT INFORMATION: Name: ProBuilt America State License 20356847 Expiration Date, 03/12 Phone; 651-770-9315 (office) (cell) Mailing Address: 2211 11th Ave a City; N, St. Paul m ZIP: 55109 Contact Person: Locher Dahl Applicant is, Contractor I Homeowner (circle ono) Email and/or Fax: nnrho-rriGnwindnuwnrl rima Cnm PROPERTY OWNER INFORMATION: Name: Shirl@v Bull Phone(day): Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits ❑Door(s) ❑ Remodel ❑Water Damage Minnohaho Crock Watorshed District(MCWD) Q Window(s) ❑ Repair ❑Storm Damage 16202 Minnetonka Blvd Deephaven.MN 55391 ❑Siding ❑Restoration ❑Other:(specify) Phone: 952-471-0590 Fax: 952-471-0682 0 Re-roof C3 Fire Damage www.minnehahacreek,ora Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ 3430 APPLICANT ACKNOWLEDGEMENT: • Drees to provide all Information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for subinitling a complete application being aware that upon failure to do so, the staff has no alternative 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 State 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 lhd data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies ro uired by low. If you refuse to supply the information,the application may not be issued. Applicant's Signature: 1494 P4�� Date: 10/23/2010 1.051 Updated: 05-04.2009