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Oct-27-2009 09:40am From-CITY OF ORONO +8522484616 T-6B4 P 003/003 F-179 <br /> . . - -- - <br /> Building Permit Application fo� lnterr�al Wark '� <br /> windows, doors, sidin , re-roof, e�tc.) <br /> ��A` Ma�ung Add►eas: <br /> �r PO Box 66 Permit number. QO - Qfl � <br /> 0 Q Crystel Bay, MN 55323-DOB6 p�te r��i�d; /D/�ly O�' <br /> � � St�eotAda�s; Recelvhd by: �� <br /> 2750 Kelley Parkwey Plen revfew fee; <br /> �k Orcna.MN 55358 �, <br /> Mam: 952�249�BOp Fax: 952-248�616 To�l Fe�e: ���� ' f <br /> This application form rnust be oompleted in fult and all required information must be submitted, <br /> Incornplabe appllcatloae wlll be�etumed. (P/eaSe prinp ' �''��� <br /> �ENERAL INF�RMATIQN: 71��G • <br /> Job Site Address: 35�c-,_�`�� • '�{;� <br /> Will thls be a Parade of Homes, Remo�elers Showcase Home or ather Display Home? Yes � No <br /> M�sa,e apeolel e�rt�per�nif is�qul�d w/M PpJ/p�p�p��,�,ent snd Crry Covxll aPA��80 deys p�iv�Iv�no eMens. 3hutrk Dus servla wM pa <br /> �equl�d��lssa ePpJk�Ont tlemonstrbles s�AhiG9nt vn,Blte perking!a 9v6deb/s. IYon.per»t/�Msd e„tlnt�wlp not be a/bwsd. <br /> CONTRACTpR/APPLICANT INFORMAT1pN: j <br /> Name: Renewel By Andersen ' <br /> 3tate Ucense# - - — ' <br /> Phone: ]920 County Road "C" We�t �xp�ration DaEe; <br /> Mailin9 Address: '-' �seville, MIV S51 l 3 . cell <br /> Cantact P�rson: License #20130983 ��y' � E�P� � <br /> Email and/or Fax: 651-264-477'] �t Is: Cont�actor / Homeowner �ati�.o�.� <br /> PROP�RTY OWN R INFORMATION: , <br /> Nan1e: � <br /> Phone(day): � <br /> Addreas: C� . <br /> Email and/or Fex Z�P� � <br /> i <br /> PROJECT INFORMAt10N: � <br /> Typo of Projaee: i ' <br /> Any aartl�movemont i►wy requlre ; <br /> ❑Door(s) �� ❑ Remodel ❑WBte�Damage MCWb revi�w 8 per�nils <br /> Minnehaha Creek Watershed Distiict(MCNID) <br /> �Wl�dow(s) ❑ Repair ; ❑ STom1 q�mafle 18'�02 Mlnnetonke�Blvd <br /> ❑Sidl�g ❑ RestOrelfon ❑Other. a eG Deaphaven, MN 55961 <br /> � p �� � Phone: 952-471-0590 I <br /> ❑ Re'�f ❑ F�fe Dam6lge Fax: 952-471-0882 <br /> Overall Pro ect De�crf on: � ��� �� fi � <br /> Estima�ed Conetruclion Valustl n of Pro�ct(excludin land) ; <br /> APPLICANT ACKNOWLEDaEMENT: <br /> • Agrees to provld�all informalion requircd or�eque9ted by the Building Departrr�eRt; � <br /> • Ce�ti�es that the Infortn8tion supplled Is uue end corr@d to the best of hisfier knowledge. The applieant recOgnizep thet It�ey <br /> atb solely reeponslble for submitting a aomplete appllcation being aware that upon failure tr� do so, Ihe etaff t18s no�l6mative <br /> bu1 to r�Je�ft until it Is complete: <br /> � Some or all of ths irtformation that yau ere esked t0 provlde On thia ppplicatlOn is claasl6ed Dy S1ate law as eltho►prlv�bg or <br /> confldent(el Pnvate data is information whlch generally cennpt be given to the publle but cen be g(ven b the subje�i of ths <br /> date. Conf►dential date is Pniormatlon which eenarslly cannot be gnren to either the puhl�c or the BubJect of the dat�. Our <br /> purpace and intended use af th�s infonne►lon is to �nnually update out raco►da and reoer�ia of other governmental egeneies <br /> ulr9d b lew. If ou r�fuse to gu I the Vntormation the a Ifcation me not be Issued. <br /> Appticant's Signature: Date: � <br /> Leat Updeted� 05-042006 <br /> Z 'd 06 T 9bG9 T S9 3�I/12J3S 1 I W?!3d Q 9 S NI SE =S T BOOZ 9Z ���0 <br />