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Aug 2510 09:1 1a Rider Home Improvement 651-994-8292 p.2 3,uo-25-2010 08:34am From-CITY OF ORONO +9529494616 T-43T P.001/00I F-569 '-•Fry OT Orono Building Permit Application for Internal Wo• rk (windows, doors, siding, re-roof, etc,) Mailing Address: '� PO Box 66 Permit number: b7b/p 4„, - 0 Vi Q Crystal Bay, MN 55323-0066 Date received: • 7/a5p 14. L? =" y. Street Address: Received by: • 2750 Kelley Parkway og� Orono,MN 55356 Plan review .14t4 ;11 Main: 952.249-4600 Fax: 952.249-4616 www.ci.orono,mn.Us Total Fee: "�� This application form must be completed in full and all required information must be submitte/d. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: (�O. S CJ 1 /4j Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No If yes,a special avant permit is required with Polkas Department and City Council approve/60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sutf/Ctent on-site perking is avai/ebte. Non-permitted events.will not be allowed. CONTRACTOR/APP ICANT INF• - Tia • Name: State License# ..� i F�c Phone: Piration Date: Mailing Address: '/ y6 (office) (cell) Contact Person: ___7_0c7 �� -�� !' . v 612 City: > 74- _ 21P: Ernail and/or Fax: •6-51.---;?,9/ _s2- p, D_ Applicant is: Contractor I Homeowner (circle onto PROPERTY OWNER INFORMATION: Name: `fly C7 S S Phone (day): _— Address: ' we �� fJi� 2?/ City: Email and/or Fax Oc U ZIP: PROJECT INFORMATION: Type of Project: Any earth movemerrt may require Q Door(s) ❑ Remodel MC1ND review&permits �]Water Damage ©Window(s) ]Repair Minnehaha Creek Watershed District(MCWD) ❑Storm Damage 18202 Minnetonka Blvd DeeO Siding ❑ Restoration ❑Other (specify) Phone; 952-4aven, 71-0590 i9-roof Fax: 952-47T-0682 t 0 Fire Damage ww••,minnehahacreek_oro Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ � e7.0c, APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to -.•. the informeti.• .e application may riot be issued. Applicant's Signature: Date: _ �_� /0 Last Updated: 052009