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89. 5c") <br /> a. 10 I City of Orono <br /> q ). 9al Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> 0.� PO Box 66 <br /> 0 lO , Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> XEssos' Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us I <br /> Total Fee: <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: 074o Loa\IKX-j "?dr q <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Renewal By Andersen <br /> State License# 1920 County Road "C" West Expiration Date: <br /> Phone: Roseville, MN 55113 - (cell) <br /> Mailing Address: City: Zip: <br /> Contact Person: License #20130983 t is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: 651-264-4777 <br /> PROPERTY OWNER INFORMATION: <br /> Name: W'.\\_dj vh �ttS e <br /> Phone (day): _ �..ty�� <br /> Address: LS. City: zip: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: -F�0.C_k 1 docrr ;rN -e�c�S�i �� Any earth movement may require <br /> oor(s) ❑ Remodel MCWD review&permits <br /> ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> Jndow(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ RestorationDeephaven, MN 55391 <br /> ❑ Other: (specify) Phone: 952-471-0590 <br /> ❑ Re-roof ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information 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 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 information is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information,the application may not be issued. <br /> Applicant's Signature: o <br /> Date: a o 9 <br /> Last Updated: 05-04-2009 <br />