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Jun-O7-2010 07:19am From-CITY OF ORONO +9522494616 T-287 P 003/003 F-18T <br /> --.. - - — - ---— <br /> Building Permit Application for Internal Work <br /> (windows; doors, sidin: , re-roof, etc.) <br /> Meiling Address: <br /> '¢Q�. PO Box HB Permit number. a7`)y,Oa <br /> (, Q Crystal Bay,MN 55323-0066 Data received: ,o�j/�o70/� <br /> ' i <br /> �.! Street Add/sss: Received by: <br /> �.i� t<� 2750 Kelley Parkway <br /> Plan review fee: <br /> `>': Orono,MN 55358 <br /> Total Pee: 1�pj01,0, <br /> Main: 952-248-4600 Fax: 952-249-4616 swfw.ci.orono.mn.u1 <br /> This application form must be completed in full and;all required information iort must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: a 5(D <br /> Job Site Address: UZ ���', -1*---Q--- <br /> 1/4II this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 Yes ❑ No <br /> if yea,a special event permit/s required with Police Department and City Council approval SO days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-slre panting is available. Nor/-permitted events will not be allowed. <br /> CONTRACTOR 1 APPLICANT INFORMATION; <br /> Name: Renewal By Andersen <br /> State License It 1920 CountyRoad "C" West Expiration Date: <br /> Phone: <br /> Mailing Andress: Roseville, MN 55113 (cell) <br /> Contact Person: License#20130983 City: ZIP: <br /> Email and/or Fax; 651-264-4777 tis: contractor / Homeowner pieta on.) <br /> PROPERTY OWNER INF RMATION: <br /> Name: iii <br /> Phone (day): (013Q-- t (Q a <br /> Address: '1 City: ZIP: <br /> Email andlor Fax •-- <br /> PROJECT INFORMATION: �� <br /> Type of Project Fat ( eAdio cfoO ' C Sf� y 4 <br /> 1`�f' i� � � • Any earth movement ma re ulntl <br /> ❑ Coor(a) ❑ Remodel MCWD review S permits <br /> . 0 Water Carnage �t �' <br /> e A Innehaha Creek V1lratershed District(MCWD) <br /> ❑Window(s) 0 Repair El Storm Damage 18202 Minnetonka Blvd <br /> Deephaven.MN 55381 <br /> ❑ Siding ❑ Restoration 0 Other: (specify) Phone! 952-471-0590 <br /> ❑Re-roof 1 1:1 Fire Damage Fax: 852 71-0882 <br /> www minnehahacreg .I <br /> Overall Project Description: <br /> Estimated Construction Valuation of Pro•ect(excludin; land $ /'1' — <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 remrds of other governmental agencies <br /> r [tired b law. If ou refuse to su I the information the a lication ma not be issued. <br /> Applicant's Signature: �� Date: Q j"1 <br /> Last Updated: 05-04-2009 <br /> a -d O6t94L9tS9 33IA213S 1IW213d a 'B S ri StP : Tt OTO2 ED unC <br />