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City of Orono <br /> Building Permit Application for Internal Work <br /> $ (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> g‘' <br /> O41--- CrBox 66 <br /> _�O� Crystal Bay, MN 55323-0066 Date received: <br /> ' -i >, Street Address: Received by: <br /> 1..�, „,;l0. Gtiti 2750 Kelley Parkway Plan review fee: <br /> l9x.6060.+ Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 'Lo ci° kAe$ 1 WA-el-A TP+ 131,01 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes allo <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: 4--X o � ��ZS( r �4 <br /> Name: WALKER ROOFING CO INC <br /> State <br /> State License# 11:2-2-6k WESTWAY EXTERIORS INC Expiration Date: 'S/3 I / / Z <br /> Phone: 2274 CAPP ROAD (office) k,s) —'7.4 (-- (Du, in (cell) <br /> Mailing Address: SAINT PAUL, MN 55114 Cit ZIP: <br /> (651)251 0910 <br /> Contact Person: DY �5,�� Applicant is: Contrac / Homeowner (circle One) <br /> Email and/or Fax: Af...cESEG bpAL.j iaRLeor=fiu4- c..,.v+ <br /> PROPERTY OWNER INFORMATION: <br /> Name: OKoNO 4-44201>S <br /> Phone(day): c{ SZ - /4 73 -bo id <br /> Address: 204 W. WAN- pg &(rJ9 City: OP.oA10 / MN ZIP: S 5 -' <br /> Email and/or Fax <br /> PROJECT INFORMATION: ____ <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> ❑ Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof ❑ Fire Damage www.minnehahacreek.org <br /> Overall Project Description: Tewi. O FP A.rJ0 (2-6 Roo 1= o F 11.46 51-hi (4 1 c J2 4 4A-Ac <br /> Estimated Construction Valuation of Project(excluding land) $ (I 21 161. 68 <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: Date: 9 i ‘,/ <br /> / /O <br /> Last Updated: 05-04-2009 <br />