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MAY/21/2014/WED 10; 34 PM Elder Jones Building FAX No. 952 854 4909 P, 002 <br /> ., . . <br /> � City o� Orono <br /> Building Permit Applicafiion for �nternal Work <br /> (windows, doors, s�ding, re-roof, efic.) <br /> /��� MailiPO Boxr66. Permit number: —� , <br /> � � Crystal 6ay, MN 55323-0066 Date received: � <br /> ' r,' Received by <br /> � iy�;!� r` ,, StreetAddress: <br /> ,F, >��� �'~F 2750 Kelley Parkway Plsn review fe <br /> �.� � n• 4,� • Orona, MN 65366 . <br /> �$sFx�_/ � �� ✓� <br /> Total Fea: <br /> Main: 952-249-4600 Fax: 952-249-4616 Www,ci.orono.mn.us <br /> Tf�is application form must be campleted in fufl and all required information must be submitted. <br /> Incomplete applicatians will be returned. (P/ease print) <br /> GENERA►L INFORMATION� � �� ^ „O ��� ��C ��( � <br /> Job Site Address: l l/ � � <br /> Will this be a Parade of Homes, Remodelers Showcase Hpme or other Display Home? ❑ Yes No <br /> 1Pyes,a specia/evenc permlt is raqulrad with Police Department and Gity Council approval 60 days Arior to the event. Snuitle bus service wi«be <br /> required unless appllcant demonstratss suff;cient onsite parking]s availab/e. Non-permitled events wlll not be al/owed. <br /> CONTRACTOR!APPLiCAN7 IN�ORMATION: <br /> Name� g�'� �YS•GoY7 <br /> State License# Pella Northland o <br /> Phone: I5300 2Sth Ave N. Ste 100 (cell) <br /> Mailirtg Acidress: �1yri10ut�],A/�55447 ZIP: <br /> Contact Person: I,�zc#BC645090 ph. 763/74�-1400 �omeowner (Gircie Onej <br /> Email and/or Fax: <br /> pi�OPERTY OWNER IIVFORMA7�pN: <br /> �vame- J c� l/� v G n <br /> Phone(day): ? 3 • / - <br /> Address L � /` � �1 �� Ci : �Q �7-(� zIP: �S 3 4 / <br /> Email and/ar Fax <br /> PROJECT INFORMA'T10N� � <br /> Type of Project: Any earth movement may r�quire <br /> NICWD review&permits <br /> ❑ Doof(S) ❑ Ramodel �Water Damage <br /> . Minnehaha Creek Watershed DistriCt(MCW�) <br /> Window(S) Repair �Storm Damage 18202 Minnetonka Bl�d <br /> Deephaven, MN 55391 <br /> ❑Siding ❑ Restoration ❑Othsr:(Specify) Phon2: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Re-roof [,� Fire Ddmage wwvv.mihnehahacreek,oro <br /> Overall Project Description: 'rj (�J //) O W ,( / � S' <br /> Estimated Constructian Valuati�n of Project(exclu ing I�nd} $ /� � 0 l7 <br /> A�'PLICANT ACKN�W�.�DGEMENT: � <br /> . Agraes to provide all information�equired or requested by the Suilding Department; <br /> . certifies that the information supplied is true and correct to the best of his/her know�edge. 1"he applicant recognizes that they <br /> are soEely responsible foP Submitting a complete appliCation being aware that upOn f2ilure to do so,the Staff h8S no alfernafiv2 <br /> but to reject it until it is complete; <br /> • SOme Or a11 of the information fhat you ara asked to provide on Yhfs appliCation is classified by StaYe law as eiChe�private or <br /> confidential. Private data is info�rnation which generally cannot be given to the public but can be given to the subjecE of the <br /> data. Confidential data is information which generally cannot be givetl to sither the public or the subject of the data. Our <br /> purpose and intended use o�this information is to annual►y update our records and records of other governmenta! agencies <br /> re uired b law. If ou refuSe to su i the i�fOPmation,the a lication ma nOt be issued. <br /> Applicant's Signature: —� �+ �l ��I <br /> v Date: <br /> /\� <br /> Last Updated: 05-04-2009 <br />