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City of Orono � �.uilding Permit Application for fnternal Work (windows, doors, siding, re-roof, etc.) O Mailing Addr�ss: '¢' �T PO Box 86 Perrnit number: � � �3(p � � Q Crystal Bay, MN 55323-0066 p ate received: J`�' /S lb � '�� F Sfieet Address: Received by: � 4$c,`' 2750 Kelley Parkway Plan review fee: ��uo Orono,MN 55356 Main: 952•249-4600 Fax: 952-249-46'18 www.ci.orono mn us T�al Fee: � � ��, �q U This application fo�rn must be completed in full and all required information must be submitted. Incomplete applications will be returned. (P/ease prinf) GENERAL INFORMATIO : Job Site Address: p`�Q l�n.� ��Q . Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes Na 1f yes,a specia/evan�permit is required with Polica Departrnent and City Counci/appmvel 60 deys pr+lor to the eyient. Shuttb bus servioe wil/be required unless applicant dem�nstrates suFfrcienf on-site psrking is availabJe, Non-permitted ev�ents wlll nat be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: Renewal By Andersen Phone icense# 1920 County Road "C" West � ' Expiration Date: Mailing Address: Roseville, MN 55113 — f�elq Contact Person: License #20130983 — C��'� ZIP� Email andlor Fax: 651-264-4777 ' �t�s: Contractor I Homeawner �ci�ieo�� PROPERTY OWNER INFORMATION: ' Name: �—"r'� Phone(day); . y-� , Address Email and/or Fax C�� Z�P� PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review� permits ❑Window(s) ❑ Repair Minnehaha Creek Watershed District(MCWD) ❑ Storrn Damage , 18202 Minnetonka Blvd ❑ Siding ❑ Restoration �eephaven, MN 55391 __ ❑Other: (specify) Phone: 952-471-0590 ❑ Re-roof Fax: 952-471-0682 ❑ Fire Damage vy�w ,minnehahacreek ora Overall Project Description: , , Estimated Construction Valuatio of Project(excluding land) $� . � � �� lD 8. OC) APPLICANT ACKNOWLEDGEMENT: • Ag�ees to provide all information required or requested by the Bullding Department; • CeR�es ihat the information supplied is true and correct to the best of his/her knowledge. The applicant recogni2es that they are solely responsible for submitting a compfete application being aware thab upon failure to do so, the staff has no aRernative but io reject it urrtil it is complete; � • 5ome or all of the information that you are asked to provide �n this application is classified by State law as either p�vate or confidential. Private data is informalion which generally cannot be given to�he 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 irrte�ded use of this infonnation is to annually update our records and records of other governmental agencies r uired b law. If ou refuse to su I the information the a lication ma not be issued. , Applicant's Signature: - Date: � Last Updaled: OS-04•2009 Z 'd 06T9�bG9iS9 3�IA�I3S 1IW213d Q '8 S f� bS =ST OIOZ GT FeW