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. City of Qrono <br /> . � � Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc. <br /> Mailing Address: Perrnit number: �,�lb_pp �,6 <br /> 'g+0� PO Box 68 <br /> Q � Crystal Bay, MN 55323-0086 Datie received: ��/ /d <br /> � ;-� � Stnset Addr�ss: Received by: <br /> � �p 2750 Kelley Parkway Plan review fee: <br /> °�c�Hoa Orono, MN 55356 <br /> Total Fee: v���,5� <br /> Main: 952-249-46D0 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be retumed. (Please pnnt) <br /> GENERAL INFORMATION: �$y� �O� <br /> Job Site Address: S �{'� �� \lh� <br /> Will this be a Parade af Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> /fyes,a specla/event permit is r�qul�d w/t�Police Department and C/ty Couna'1 approval 6D days pnor to the event Shutt/e bus senrice wiN be <br /> requirod unJess applicanF demonsbates sufficient on-site parNir�g is evailable, Non-pernritted events wi11 not be allowed. <br /> CONTRACTOR/ APPLICANT INFORMATION: <br /> Name: Renewal By Andersen <br /> State License# 1920 Coun Road "C" West Exp�ration Dat�e: <br /> Phone: �' <br /> Mailing Address: Roseville, MN 55113 (cell� <br /> License#20130983 ��tv� ZIP: <br /> Contact Person: �t is: Contractor ! Hcmeowner (Clrcle Dne) <br /> Email and/or Fax: 651-264-4777 ° <br /> PROPERTY OWNER INFOR TION; <br /> Narne: -e,. �►'� <br /> Phone {day): a <br /> Address: ; Ci ; ZIP; <br /> Email andlor Fax � , <br /> PROJECT iNFORMATION: <br /> Type of Project • <br /> ,O�CQ q 1� h� $ ,1� ..QJ��S (�p Any earth movement may require <br /> ❑ Door(s) ❑ Remodel , J MCWD reviaw 8,permits <br /> ❑Waier Damage ��Q <br /> �indow s MT�nehaha Creek Watershed District(MCWD) <br /> ( ) ❑ Repair ❑ Storm Darnage 18202 Minnetonka BWd <br /> Dee haven,MN 55391 <br /> ❑ Siding ❑Restoration ❑ Other. (spec'ify) Ph ne: 952-4T1-0580 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑Fire Damage �nrw.minnehahacreek oro <br /> Overall Pro'ect Deacription: <br /> Estimated Construction Valuation of Project(excludin land) a � 3 (�(o S .� <br /> APPLICANT ACKNOWLEDGEMENT; • <br /> • Agrees to provide all informaiion required or requested by the Building Department; <br /> • Certifies that the information s�pplied is true and correct to the besf of his/her knowiedge. The applicant reoognizes that they <br /> are solely responsible for submitting a camplete application being aware ihat upon failure to do so, the staff has no attemative <br /> but to reje�ct it until it is complete; <br /> • Some or all oi lhe inforrnalion that yo.0 are asked to provide on this application is dasslfied 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 subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subJect of the data. Our <br /> purpose and intended use of this infarmation is to annually updete our records and rocords of other govemmental agencies <br /> re uired b law. If ou refuse to u I the information the a Iication ma not be issued. <br /> Applicant's Signature: � Date: f �lUl'� �� <br /> Last Updated: 05-04-2009 <br /> Z 'd 06T9trL9TS9 3�IA213S 1IW213d Q '8 S �1 9Z =zT OTOZ TO ��C <br />