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� City of Orono <br /> . , . Building Permit Application for Internai Work <br /> windows, doors, siding, re-roof, etc.) <br /> Meiling Address: <br /> �0� PO Box 66 Permit number. a(?!' ! r'" �,,f'- . <br /> 0 � Crystal 8ay, MN 55323-0066 Date received; �` �,''C.i <br /> � <br /> a r � Street Address: Received by: _��,� <br /> � �� 2750 Kelley Parkway Plan review fe�: �r <br /> ����sxo�� Orono, MN 55356 ,,� <br /> Main: 952-249-d600 Fax: 952-249�616 wvuw,ci.orono.mn.us Total Fee: '�' ���� ��� � <br /> This application form must be cornpleted in full and all required inforrnation must be submitted. �%y <br /> Incornplete applications wlll be returned. (Please print) � �="�� �'' �"` <br /> GENERAL INFORMATION: <br /> Job Site Address: �$cj �, ,� � � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> Kyes,a specia!evanf permlt is required with Pollce Department end City Council approval 60 days pno�to the event. Shuttle bus service w�/I e <br /> raquired unless applicant demonstrates sulficient on-site perfcing/s availab/e, Non-permJtted events wil/not be a/lowed. <br /> CONTRACTOR/ APPLICANT INFORMATION: <br /> Name: Renewal By Andersen <br /> Phone:icense# 1920 County Road "C" West Expiration Date: <br /> Mailing Address; Roseville, MN 55113 (cell� <br /> License#20130983 C��� ZIP: <br /> Contact Person: �t is: Contractor / Homeowner <br /> Email and/or Fax: 651-264-4777 ' ��'"'e o"e► <br /> PROPERTY OWNER INFORMATION: `- ��11 U �� <br /> Name: '(\(� �(�1.���,e <br /> Phone(day): , y b <br /> Address: � . Ci , Z�P. <br /> Email and/or Fax � <br /> PROJECT INFORMATION: � <br /> Type of Project; <br /> Any earth movement may requlre <br /> ❑ Door(s) ❑ Remodel N�CWD review 8 permits <br /> ❑Wat�r Oamage <br /> ❑Window(s) ❑ Repair Minnehaha Creek Watershed District(MCWD) <br /> ❑ Storm Darnage 18202 Minnetonka Blvd <br /> ❑Siding ❑Restoration ❑ Other: (specify) Ph neaV952 4N1 0590 <br /> ❑ Re-roof Fax: 952-471-0662 <br /> ❑ Fire Damage w�w.minnehahacreek ora <br /> overall Project Description: p`� � � •o �� �� �� i <br /> Estimated Conatruction Valuation of Project(excluding land) $ � . (� <br /> i <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Departmenl; <br /> • Certifies that the inforrnation supplied is true and correct to ihe best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upvn failure to do so, the staff has no alternative <br /> but lo 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 5tate law as either private or <br /> confidential. Private data is informatiqn which generally cannot be given to ihe pu6lic but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to eithe� the public or the subject of the data. Our <br /> purpose and intended u5e oi this information is to ahnually update our records and records of other governmental agenaes <br /> re uired b law. If ou refuse to su I the information the a lication ma not be issued. <br /> ApplicanYs Signature: Date: � J� <br /> Last Updated; 05-04-2009 • , <br /> Z 'd 06i9trL9TS9 3�I11213S 1IW213d Q '8 S �1 OE =9T OTOz EO �eW <br />