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Nov-17-ZO10 02:42am From-CITY OF ORONO +9522494616 T-638 P.002/002 F-076 <br /> Clty of Orono - . <br /> Building Perm�t Application for Infiernal Work <br /> (windows, doors� sidi�g, re..roof, etc_) <br /> MsllingAddress' Permitnumber. �/D-D//„3 , <br /> O.�0�� PO Box 66 � <br /> crystat 8ay, MN 56a2s.0066 bate received: / d <br /> ,a SIlB6f Add/�ess' Received by: <br /> � 275�Kelley Perkway � Pian revi�w fee: <br /> �� og�� . Orono,MN 55356 � <br /> ToTdl Fe9: a fl, � � <br /> Main� 952-2�9-a600 Fax: 962-249�6�6 wvuw.si�4,mn.us . . <br /> Thls applfca�on forrn musT be compl�ted in full and ell r�qulrcd infnrmation must bs submlttod.�_. . _ .� <br /> , • � Incomplete appllcations wil!be returned. (P/ease prin!) , , <br /> GEN�RAL INFORMATION: ' /'� _ � , . <br /> ..:�' � <br /> ^`�ta.b-�e�ress�. ,.. _., l��— -�1�-y�-----�- �1�*--. . <br /> Will this b�a Parade of Homes, Remodelers 5ho�vcase Mome or other Display Home, Yss���. �� 0�No <br /> � 1f yes,a speaia!avsnt psimlf Js requ�red wlth Polica oepertment and Clty Councll approvel 60 days prJor tc the evant. Shuftle bus sarvica wld ba <br /> reqvlrod�nloss appli�cant damonstrafas su{ficJe�!on�slfe pbrkinA is avalleble. Non•ae�mrrrea evenfa v�nU nar 6a a�rowed. <br /> GONTRACTOR!APP4.ICANT INFORMATION: � • <br /> Name, � , Jo-d� � F/el*f Jnn�s <br /> State�icense# Pella Windows &Doors R,�� k - a��'7 <br /> Phone: 15300 25th Ave N. Ste I 00 _. � (aell) <br /> Mailing Address: , plymout�Z,N�N 554q�7 Z�P_ <br /> Contact Person; I.ic#2016588�1 Ph. 763/745�1400 � �°'necwner �c���ona► <br /> �mail and/or Fax: — <br /> PROPERTY owN�R NFORmaTi w: , . . •. • <br /> Name: �/G /1 � 1'��/ � � � <br /> Phone(day): ' �/� 4� B�• �� �' � <br /> Addres5; /%��v �/S d 5 t �l'�. City: _ ZIP: <br /> �mail andlor Fax �� � <br /> PROJ�CT IN�ORMATION: <br /> Typo Projeot' Any,earlh moven,ent may r�+quire <br /> MCWD revlaw R�parmlt6 . <br /> ❑ poor(s) ❑Ramodal ❑�Nater pamape � ., <br /> Minnehaha Creok WstE�rshed Aistrlat(MCVVD) <br /> Window(s) Q Repair ❑Starm Dama�e '18202 Minn�,fonka Blvd <br /> , • Deephavan, MN 55991 <br /> ❑Slding ❑Restofatl011 ❑Other:(apocify) Phone= 95:!-491-U690 _ • <br /> Faz� 9b2-�71•0682 <br /> Q �c�oof ❑Fi►e De aqe ,innNur- %�ha�ak-org . , <br /> OVerall Pro eot beacr7 t(on: G,� n / �/1 �d.7��1 i�� C <br /> E�tlmated Constructlon Valuat7on of Projoct(exclu ing Iend) S /Q� 7 � L: ' . . . <br /> App�ICANT ACKNOWLEDGEMENT: <br /> • Agrees tn provide all Intormetion iequiretl or requesteo dy me 6ullding Dopanm�nt; ' <br /> ■ Certifies that the Infiormatinn supPNed Is true end rnrrect to the bssf aP his/her knowled�e. The �ppllcant lecognizes that they <br /> are solely responslble 1or submltting a oomplete application being awsra that upon fallure to ao sa, tne s�att nas no alternative <br /> hut to rejeG R until it is complete; , <br /> • Samo or 311 Of ih0 ��format�on that vou are asked to provlde on thls appllcatfon is classlfted by Sta�e law as elther private or <br /> coMldentlal. Prlvate data is information whlch ge�ertlly cennOt be glven to the pUbl�c but can be c�)ve� to the subject Of ttle <br /> data. Gonfldentfel data Is Informatlon which Benerally cannot ba glven to eimer me publlc.of 2he suojece of tne data_ our <br /> purpose and Intendsd use af Zhle fnfarmafion is to annually update our records and racord� of other govemmental agenc�as <br /> _ required Dy law tf Xou rsfuse io suoplx tha InformaMon,the appllcation msy nof bv issued. <br /> ApplicanYs Slgnature: _ �'l��- o� Date: ` (` ` 7 ( �� <br /> X <br /> Last UpOat�d: 06-04•200a <br />