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MaV `L4 2009 8: 09PM HP LASERJET FAX p. 2 <br /> ` City of Orono <br /> Building Permit Application <br /> Mailing Address: • <br /> et I tlumen: d <br /> 0.� PO Box 88 Peb ,>�i.:. : ..:.: <br /> Crystal Bay,MN 55323-0066 DetA.tiaoafu�eid:. 9. <br /> Sheet Address: Rnrsd.41L <br /> 2750 Kelley Parkway PunVJ : <br /> Orono,MN 55358 <br /> Te>Isl Pae: <br /> Main: 952-249-4600 Fax: 952-2494616 www.d.orono.mn.ua <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: 2702 Walters Port Lane <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 yes No <br /> Ityes,a special avant Penn#is requked w6h PbNce Department and City Council approval 60 days prior lb the event 8huttwe bus senalee wN be <br /> required uNass applicant demonstrates auAlmnt on-alts paddy is ovellabte. Abn-pem&W events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Northrup Roofing&Remodeling <br /> State License# 20338983 Expiration Date: 03/31/10 <br /> Phone: (612)825-3353 (office) (612)363-7443 (cell) <br /> Mailing Address: 4400 NlcolletAvenue City: Minnesoolis ZIP: 55419 <br /> Contact Person: Stu Hudson Applicant is: Contractor ! . Homeowner lcr►eis om) <br /> Email and/or Fax: ranaeghnorthniprooflng.comif ti 612-825-1900 <br /> . e <br /> PROPERTY OWNER INFORMATION: <br /> Name: Andrew McDermott <br /> Phone(day): (612)310-6922 <br /> Address: 2702 Walters Port Lane City: Excelsior• ZIP: 55331 <br /> Email and/or Fax andrew mcdermottOlws.aov <br /> PROJECT INFORMATION: <br /> Type of Prole Any earth movement may require <br /> O Door(s) ®Remodel ❑Water Damage MCMYD review&permits <br /> Water <br /> hed <br /> 0 Window(s) >g Minnehaha Creat Minnetonka nka Blvd�(MCWD) <br /> (0'I�epair ❑Storm Dam18202 <br /> Deephaven, MN 55391 <br /> Siding <br /> Q Restoration C3 Other. (specify) Phone: 952-471-0590 <br /> M Re-roof Fax: 952-471-0682 <br /> Firm Damage yea w minnehahacreek.ora <br /> Overall Project Description: Remove 8 Replace Wood Shake Roof <br /> Estimated Construction Valuation of Project(excluding land) S 15,000.00 <br /> 41PPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information requlmd 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 adely responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemativve <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. Privets data Is infatuation 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 information is to annually update our records and records of other govemmental agendas <br /> required by law. If you refuse to supply the information,the application may notbe issued. <br /> Applicants Signature. Date. <br />