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Ju1 . 21 . 2011 1 : 32PM AMEK CONSTRUCTION INC. No. 9306 P. 2 <br /> City of Orono �#\6 <br /> $5 <br /> Building Permit Application for Internal Work <br /> windows, doors, siding., re-roof, etc.) <br /> Mailing Addreae :;>•.....: ..�;:,;..>.:::• :.::;r ,::,:::• .. ;�:::;;,• <br /> O PO Box 66 : f?.81it111t;r�ur ('•;:;:;'':::' . ::;i� ::` '. <br /> 0 Crystal Bay,MN 55323-0088 'PAt :;tiaCeircl ;: ••'•:'':``::'.:':`' ?:•::'`:: ::< '.. ; <br /> StreetAddroes: <br /> 2750 Kelley Parkway :.4,.;•.,. , <br /> Orono,MN 55356 <br /> Mein: 952 249.4600 Fax: 952 249-4816 l,cf.orono.mn.us <br /> This appllcation form must be completed in i and all required information must be eubmine . <br /> GENERAL INFORMATION: Incomplete applications will be retumed. (Phase print) <br /> Job Site Address: 1355 YIK-Ne- <br /> Will this be a Parade of Hones,Ramodelers Showomw Home or other Display Home? Yes AUNo <br /> Nye*a spedaf event pem*is ngdred%Wh Polka Depsibrwnt and C ityCoundl approW So doe prtor to the Mni. shuffle but"Mee Vd#be <br /> mgrdr d urdess eppbasnt damonahstee&Akd&*mmo parking h am?aue. Mon-pemrtted everts M#not be allowed. <br /> CONTRACTOR/AP CAI INF RMATION: <br /> Name: .I lAges L <br /> State Llcense# 201 Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for Work on home" conatrerofvd LO 1978 <br /> Phone: M 2^ —2 -n!�! (office) (cell) <br /> Malling Address: Q g— 5 ]ZIP., ,glv/ <br /> Contact Person: ApplIs: Contracto omeowner Icirde one) <br /> Ismail and/or Fax: C7,%T 2 62&KY <br /> PROPERTY OWNER,1 FORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP., <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ❑Remodel ❑WOW Damage MCWD review&pemdb: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑Repair ❑Storm Damage 16202 Minnetonka Blvd <br /> [ISiding ❑Restoration [3 Ober(specify) Deephaven,MN 55391 <br /> Phone: 952-471-0580 <br /> '5e-roof ❑Fre Damage Fax 952-471-082 <br /> bom.minnehahacreek.oro <br /> Overall Project Descrl ion: <br /> Estimated Construction Valuation of Project(excluding land $ d oO <br /> APPUCANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all Information required or requested by the BuNding 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 applicakion being aware that upon failure to do so,the staff has no altemative <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 classified 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 data is Information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and Intended use of this Infos tion is to armudly update our records and records of other governmental agencies <br /> required b . I efluae on 1h application may not be lowed. <br /> Applicant's Signature: Date: <br /> Lest Updated: 0301,2011 <br />