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MA��21/2014/WED 02:27 AM Elder Jones Building FAX No, 952 854 4909 P, 002 <br />,- • ► <br /> City of Orano � <br /> Building Perr�it Application for Infiernal Work <br /> (windows, doors, siding, re�roaf, �tc�) � <br /> �. MailingAddress: Permit number: - 7 <br /> �p.�Q,j�Q PO Box 66 <br /> Crystal Bay. MN 55323-0066. Date received: "�,• -'/� <br /> �`���•. Received by: <br /> �3 ,�:�� �, 5treetAddress: <br /> � �' Y Y Plan reviaw fee: <br /> �^.d, ;� �r�"9� �ti� 275p KeRe Parkwa <br /> � � t�°"� � Orono, MN 55356 /s��� <br /> ���8�/ Total Fee: <br /> Main: 952-249-4600 �'ax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be compfeted in fuI) and all required information must be submitted. <br /> Incompfete applic�tions wili be returned_ (Please print) <br /> GENERAL lNFORMATION: � 5. � � //� // �� � <br /> Job Site Address: t� L � <br /> Will this be a Parade of Homes, Remodelers Shc�wcase ome or other Display Home? ❑ Yes No <br /> !f yes,a special event permif�s rpquirad with Police Department and City Council approva/60 days prior to the evenf. Snuttle bus sen�ice wifl be <br /> required unless applicant demonstrates s�cient on-site Aarking is available. IVon-permitted events will not be a!lowed. <br /> CONTRACTOR!ApPLIGANi'1[VFORMATIQl3: <br /> Name. g5 a/3Y� •G p� 7. Jo4: <br /> State License# Pella Nortl�land <br /> Phone: 15300 25t1�Ave N. Ste 100 Ce�� <br /> Mailing Address: ���p����5�,¢q.'] zlp: <br /> Contact Person: Lie#BC645090 Ph. 763/745-1400 �omeowner �c���e o„e� <br /> �maiE and/or Fax: <br /> PROP�RTY OWNER lNFORMATfON: ��� y��� � <br /> Name: �y <br /> Phone(day): S 2/� • h� 7 <br /> Address: � 11 �VG Gi �rPl.lS/o !' ZIP: ���c� <br /> Email and/or Fax <br /> PROJEGT{NFORMATION: <br /> 7ype of ProJect: Ar�y earth movement may require <br /> MCWD review&permits <br /> �Goar�s) ❑Remodef ❑WaYer Damage <br /> Minnehaha Creak Watershed DistriCt(MCWD) <br /> �Window(5) Repair �(Storm E?amage �8202 Nlinnetonka Blvd <br /> � Deephaven,MN 55391 <br /> ❑Siding ("]Restoration ❑ Other.(specriy) phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> [,�J Re-r00'F � Fire Damage wWw,mirinehahacreek.ord <br /> Overall Project Description: O r n q��u/' !`t� Q C,� L �! P / � �� <br /> Estimated Construction Valuati�n of Project(excluding iand) $ (r $ <br /> APP�ICANT ACKNOWLEDG�M�NT: � ' <br /> • Agrees CO provide all information required o�requested by the 6uilding D�partment; <br /> . Certifies that the information suppl9ed is true and correct to the best of his/her knowledge. The applicant recognizes Cnat they <br /> are solely responsible for submEtting a complete application being aware that upon failure to do so, the staff has no aitemative <br /> but i0 f2jeCt it Until it is complete; <br /> * Some or ali of the information that you ara asked to provide on this appliCation is classified by Stats law as either private or <br /> �pnfidential. Private dat� is iftfOflhBtion which generally cannot be given to the pUbliC but can be given t0 the subject of the <br /> data. Gonfidential data is information which gsnerally cannot be given to either the publie or tha subject of the data. Our <br /> purpose and intended use of this informaUon is ta annually updaYs our records and records of other governmental agencies <br /> re uired p law. 1f ou refuse to su I tne information the a licatipn ma not be issued. <br /> � �[ a ���y <br /> Applicant's Signatur�: �/� Qate: <br /> x <br /> Last Updated: 05-04-2008 <br />