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, , City of Orono <br /> � � Building Permit Application for lnternal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: D ID � <br /> '��� PO Box 66 Permit number: <br /> � , Q Crystal Bay, MN 55323-00B6 Date received� /O <br /> s <br /> �`.. F�• Street Address: Received by: <br /> �� 2750 Kelley Parkway Plan review fee: <br /> ��t�Hd¢��' Orono, MN 55356 � <br /> Main: y52-249-4800 Fax: 952-249-46'IB www,ci.orono mn.uc_ To1al Fee; ��l� �D <br /> This application form must be completed in fe�ll and all required information must be submitted. <br /> Incomplefie applications will be returned. (Please print) <br /> GENERAL INFORMATIO j:� �a���{ Lt ' � <br /> Job Site Addres�: n� ` <br /> Will this be a Parade of Homes, Rem�delers Showcase Home or other Display Home? Yes No <br /> If}res,a specia!event percni�is requi�ed�vith Police DepaRment and City Council appruva/60 days prior to the evenf. Shuttle bus seivice will be <br /> required un/ess app!lcant demonstrafes sufficient on-siGe parkirtg is available. Non per�itNed events will not be a/bwed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: _ Renewal By Andersen <br /> State License# (920 Count Road "C" West Expiration Date: <br /> Phone: y <br /> Mailing Address: Roseville, MN 55113 (cell) <br /> ` License #20130983 C�tv' Z�P: <br /> Contact Person: �t is: Contractor 1 Homeowner (CfrcleOne) <br /> Email andlor Fax� 651-264-4777 <br /> PROPERTY OWNEFt INFORMA�jO� <br /> Name: �_�{� r� � <br /> Phone (day): _ " 1` . ar.y .t_�.(�Ynl n <br /> Address: _ - � v Cit : Z�p; <br /> Emaii and/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: <br /> Any earth movement may require <br /> MCWD review S ermib <br /> ❑ Door(s) ❑ Remodel ❑Water Damage P <br /> ❑Window(s) �Re �� Minnehaha Creek Watershed District(MCWD) <br /> Pa� ❑ Storm Darnage 16202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration Deephaven, MN 55391 <br /> ❑ Other: (specify) Phone: 952-471-0590 <br /> ❑ Re-roof Fax: 952-471-0682 . <br /> ❑ Fire Damage www,minnehahac-�eek ora <br /> Overall Pro'ect D�crlption: ' � <br /> Estimated Construction Valuation of Project(excludin land) $ � �. <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide atl information required or requested by the Building Depa�tment; <br /> • Certifles that the infortnation supplied (s true and correct to the best of his/her knowledge. The applicant recognizes thet they <br /> are solefy responsible for submitting a compiete application being aware that upon failure to do so, the staff has no altemative <br /> but ta reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this appfication is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subjed of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. �Jur <br /> purpose and intended use of this information is to annually update our records and records of other govemmental agencies <br /> �e ulred b law. If ou refuse to s ( the informatio a lication ma not be issued. <br /> Applicant's Signature: a : � {� O <br /> , � <br /> Last Updated: OS-04-2009 <br /> Z 'd 06I9�+L9IS9 3�IA�13S 1IW213d Q B S f� 6Z =6 OTOZ b0 ��d <br />