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City of Orono � � � Building Perrnit Application for Internal Work (windows, doors, sidin , re-roof, etc.) MallingAddress: Permi!�umber: '�0� PO 8ox 66 Q � Crystal Bay, MN 55323-0066 Date received: f� �• Stneet Address: Received by: � • �� 2750 Kelley Parkway Plan rev'iew fee; �e��Ho�� O�ono, MN 55356 Total Fee: Main: 952-24�4800 Fax: 952-249-4816 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete appltcations will be retumed. (Please print) GENERAL INFORMATION: Job Site Address: SS �6�df,� v�•Q.W i�f i Will this be a Parade of Homes, Remodelers Showcase Home or other Display Horne? Yes No If yes,a specie!event permit is�qulred with Po!!ce Department and City Council approval 60 days priw to the event. Shuttle bus service will De ►Cquired unless applicani demonsh�fes s�cient on-sJte pa�cing ls svailab/e. Non-permftted events wil!not be alJowed. CQNTRACTOR 1 APPLICANT INFORMATION: Name: Kenewal tiy Andersen State License# 1920 County Road "C" West Expiration Date: Pnone: Roseville, MN 55113 (cell) Mailing Address: License#BC130983 Ciry: 21P: Contact Person: �t is; Contractor / Homeowner �c�c�a o�e► Email andlor Fax: 651-264-4777 PROPERTY OWNER INFORMATION: Name: ,� � �� Phone(day)� 95 • 99 �-Sa4p Aad�ess: �►,e.� r. c�t : ziP: Ernail andlor Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel MCWD review 8 perm(ts ❑Water Damage ❑ Window(s) ❑ Repair Minnehaha Creek WaterShed OlstriCt(MCWD) ❑Storm Damage 18202 Minnetonka 81vd Deephaven, MN 55391 ❑ Sidin9 ❑ Rastoratfon ❑Other: s c ( Pe ffY) Phone: 952-471-0590 ❑ Re-roof ❑ Fire Darnage Fax: 952-471-DB62 www,minnehahacreek.ora Overnll Project Description: p� � •� p WS w �n ..Q�� Estlmated Constructian Valuation of Project(excluding land) $ a�j� �-9 �.0� APPLICANT ACFCNOWLEDGEMENT: � • Agrees to provide all information required o�requested by the 6uilding Department; • CertiBes that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submiiting a complete application being aware that upon f�ilure 10 da so,the staff has no alternative but to reject it untll it is complete; • Some or atl of the information ihat you are asked to provide on this application is classified by State law as either private or confiderrtial. Private data is inforrnation whlch generally cannot be given to the public but can be given to the subject of ihe data. Confldential data is information which generally cannot be given to either the pub{ic or the subjed of the data. Our purpose and intended use of this information is to annually update our reoords and records of other governmenlal agenaes re uired b law. If ou refuse to su I the information the a lication ma not be issued. ApplicanYs Signature: 3 � ��' I 2 Date: Last Updated: 05-04-2008 z 'd 06T9trG9iS9 3�IA213S 1IW213d Q '8 S f� f�b =9T ZiOz OE �dd