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DEC/09/2013/MON 12:33 AM Elder Jones Building FAX No, 952 854 4909 P, 002 <br /> 0 P-1 <br /> City of iJrono kill <br /> Building PerMit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: D 13—6 1275 <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: 2'1 <br /> o., 13 <br /> . oSReceived by: <br /> i~ Street Address: <br /> 2750 Kelley Parkway Plan review fee: <br /> Orono,MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www d.orono.m_mus Total Fee: A <br /> This application form must be completed in full and all required information must be submitted, <br /> incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: y q ,?, /V �,�� C�,� ��.J.V c <br /> Job Site Address: Ar <br /> Will this be a parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> lF yes,a special event permit is required with Police Dapartment and City Council approval 60 days prior to the event. Shuttle bus service wip be <br /> required unless applicant dem•onstrates sulfiClent on-S/te parking is available. Non-permitted wants will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Pella Northland <br /> State License# (cell) <br /> Phone: 15300 25th Ave N. Ste 100 <br /> Mailing Address: Plymouth,MN 55447 z1p: <br /> lomeowner (cireie One) <br /> Contact Person: Lemic#BC645090 Ph. 763/745-1400 <br /> Email and/or Fax: <br /> PROPERTY OWNER INFO MA ION- <br /> Name: t fL Rya n <br /> Phone(day): G 1-71 8 L 5 -, 7 L f �' <br /> Address: o �' �J a `4 ZIP: �3 L <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project, Any earth movement may require <br /> MCWD review&permits <br /> `cNoor(s) %P*�ib ❑Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> Windows) < </ ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑Siding ❑Restoration ❑Other.(specify) phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Re-roof ❑Fire Damage vA".minne hacree .or <br /> Overall Project Description: Iq W /I do ti �' <br /> Estimated Construction Valuation of Project(excluding land) $ Z 'S <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> but to reject it until it is complete: <br /> Some or all of the information that you are asked to provide on this application 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 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 information Is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the information,the ap2lication may not be issued. <br /> Applicant's Signature: Date: <br /> -113 <br /> Last Updates: 05-04-2009 <br />