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A1 , 27 , 2011 1 : 32PM AMEK CONSTRUCTION INC. No . 9306 P . 3 <br /> City of Orono F�5 <br /> BuildingPermit emit Application for Internal Wo <br /> (windows, doorssidin , re-roof etc.) <br /> AWng Address: :,;::::.;:,::.:- .r <br /> O PO Box 66 <br /> Ret °iUi!1n� <br /> 0 Crystal Bay, MN 55323-0088 <br /> 2750 Kelley Parkway <br /> .�<PiaiirY,l'�!I'+.fi9ie�>',';• <br /> Orono MN 511358 ' ;:':::"�;'';`*"'::•:;:; :;.:::::?;?:;<...:; <br /> Main: 852-24911600 Fax; 952-2484616 +WWw.d.orono.mn.us <br /> This application form must be completed in lull and all required Irtformation must be submitted. <br /> Incomplete applications will be mtumed. (Please print) <br /> Job Site Address: <br /> GENERAL INFORMATION: S2 5 V <br /> •PQ <br /> Will this be a Parade of Horns,Rerriodelers Showcase Home or other Display Homer U Yea Myo, <br /> /tyee,a spedel event pam is mgtdmdv*h Pbiloe Departnunt and CoCoundl approwsl 60 days pdorto the event Shuttle bus senwoe mo be <br /> Amp ed unless appioant dernonebates suArawd on-site paitdng is available. Non-penNNed everts WN not be allowed. <br /> CONTRACTOR I APPUCAN INXORMATION: <br /> Name: VI �eas <br /> State License# Z 01 D Expiration Date: 3 <br /> Lead Certification Number. -Ir-1M 5?- O D fl 0 R Expiration Date: <br /> (Mor work on homes d-W AWMIledprior 48 <br /> Phone: r — <br /> Mailing Address: p Zip: 37/ <br /> Contact Person: Applicant is: Contractor M Homeowner (cirew one) <br /> Email and/or Fax: 2.- <br /> PROPERTY OWNER INFORMATIOW <br /> Name: 'QMQ or 1 1')824 °tom calfaw <br /> Phone(day): <br /> Address: CRY: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Docr(s) ❑Remodel ❑Water Damage MCWD review a permits: <br /> Minnahshe Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding ❑Restoration ❑Other.(specify) Desphaven,MN 55391 <br /> Phone: 952-471-0590 <br /> 3Qe-roof ❑Fire Damage Fax: 952471-0882 <br /> www.mdnnehahaeEggk.org <br /> Overall Project DeseA n: <br /> Estimated Construction Valuation of P act(excludirmland i Ira. r7bff <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all IMbrmsfon required or requested by the Building Department, <br /> • Certifies that the Information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classilled by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential darts is information which generally cannot be given m either the public or the subject of the date. our <br /> purpose and intended use of this information is to annualty update our records and records of other governmental agencies <br /> e ui s law. 11ou re s aoDkellion may not be issued. <br /> Appliarifs Signature: pate: <br /> Last updated: 03-01-MI 1 <br />