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Swr=02-2010 08:OOam From-CITY OF ORONO +8522484616 T-465 P.002/002 F-630 <br /> �ity oT urono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, �e-rvof� etc.) <br /> �O A� Mal!O B X�• Pertnit number: D/D-D��9 <br /> O ��Q C ry9tal Bey, MN 55323-0066 Qilte reoaived: /O <br /> ��; ,, Srreer Addnass: Reoe{ved by: <br /> � � 2750 Kelley Parkwey � plen revisw <br /> � �o� �rono,MN 65358 <br /> Main: 952-249-4600 Fax: 952-Z48-4618 www,G.ornnn.mn,ua <br /> 1Total Fe�: L��� <br /> This appNcation form must be compleDed in full and al) required information muet be submitted. <br /> Incompleb�applicatlons wlll be�atu�n�d. (PleaBe print) <br /> GEN�RAL INFORMATION: *�q p�� r� ` <br /> Job 81te Address: _ or 1� C► _ �0.�;,0 T�hT_� <br /> V1li11 this be� Parade of Homes, Remodelers Showcase Home ar other Di�play Hame? Yea No <br /> II yps,s apsc/qi event poMfM Is ro qulied wlth PoJlee Department 4nd Clry CouneU epp�ovel 8C doys pifor lo b�s pv�n1. Shuttle bus soivics wid be <br /> roqalred rJNess eppllC9IN demon�RBfae sulNCienr on-sIM parking!s evellebls. No�permllted av�enfs wUl not be ellowsd. <br /> CON7RACTOR/APPLICANT INFORNWTION: <br /> Nam�: � <br /> Renewal By Andersen <br /> Stste License# 1920 County Road "C" West � �P��tion Date: <br /> PhOf'e' Roseville, MN 55113 (���) <br /> Mailing Addresa: License !#20130983 Cit : ZIP: <br /> Contact Pe�son: �t fs: Contractor / Homeowner �cucw an�) <br /> Email and/or Fax� 651-264-4777 <br /> PROPER�'Y OWNER INFORMATfON: 1� <br /> Nama: �� r� SG�'1U�T�. _ _ __ _ <br /> Phone(day}: � � O _, <br /> Address� "'� ' City: zIP: <br /> Emeil and/or F�x <br /> , . <br /> PROJECT 1NFORMATION: � ' � � <br /> typ�o/Pro�Ct: Any aerth mov�ment may requlre <br /> 11ACW0 nvlew 3 pannite <br /> �.Dcor(s} [J Remodel ❑Wster Darnage <br /> Minnehaha G•eek Watersh6d Distritt(MCWD) <br /> , ❑Window(s) [� Repalr []8torm Damage 1B20Z MinnetOnka BNd <br /> � . Deephaven,MN 65391 <br /> ❑5idtng ❑Restorddon ❑Other;(specity) Phone: 952-471-0590 <br /> �=ax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire pama�e _ www.minnehst�acreek.ora <br /> Overe{t Pro oct Dascrlptlon: W � ��� � . <br /> Estfmated Construetfon Valuatfo of Prioaect�e cludlnRland) s a,y a?.00 <br /> APPl.ICANt ACKNOWLEDGEMENT: <br /> . Agreea to prov�de ail information required or requeated by the Building Department; <br /> • Ce�flfiea thdt the iMormalfon supplied ie tn�a ane correct tv the best of his/her knowledge. The appllCent rocognizes that th6y <br /> are eolely respnnaible far 8ubmitling a oomplete aQpGcatlon being awere that upon tailure to do so, the 8tafF hae no altemaUve <br /> but fo reject tt umll it is Complete; i <br /> • Some Or sf! of tha infom�ation that you ar� asked to provide on this �p�licetlpn �a dassifiad by SCate 1ew as eiiher ptivete or <br /> confidential. Prlvate data la infortnation which generally Cannot De gfven io the publlC but cen be given to the subj6ct of the <br /> data. ConfiOential data is iniormatbn which generally cannot be piven to either the publlC or the Bu�ect of the de�te. Ou� <br /> purpose and Inte�ded usB of this (Mo�matlon is to ennually updste our rewrds 8nd records of other govemmentef agenaes <br /> uired b law. If u refuae to su 1 the infonnatlon the liCetion ma not be lanued. <br /> Applicant's Slgnsture: vv Qate: _� �,,��O <br /> :asi updatod; OS-04-2oD9 <br /> 2 •d 06T94L9TS9 3�IA213S lYWtl3d Q R S M bE =6 OTOZ TO daS <br />