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OCT/19/2011/WED 02:23 AM Elder Jones Building FAX No, 952 854 4909 P, 002 City of Orono Building Permit Application for Internal Work (windows, doors, siding, re-roof, etc.) hh', Mailing Address: Permit number: O/�•' I 0`rte Crystal Say,MN 55323-0066 PO BOX 66 Date received: Street Address. Received by: Gwti 2750 Kelley Parkway Plan review fee: o�fn Orono,MN 55356 Total Fee: Main: 962-249-4600 Fax: 962-249-4616 M.U21 This application form must be completed in full and all required Information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: �'� Nor r 1 t /i A r f /) U-C Job Site Address: 'V 7irl Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ElYes No If yes,a speolal event pennif is required with Police Department and City Council approval 60 days prior fo the event shuffle bus service will be required unless applicant demonstrates sufficient onsife parking is available. Non-pennitled events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: /p U Name: •J State license# Pella Windows&Doors 9 5� 3 y S • � o V y Phone: 15300 25th Ave N. Ste 100 cell ZIP: Mailing Address: Plymouth,MN 55447 Contact Parson: icmeow+ner ictal.anal Email and/or Fax: Lio#20165884 Pia. 763/745-1400 PROPERTY OWNER INFORMATION: Name: c,/a A n ® u A M 11 Phone(day); V 7 7 Ci : (J 4 p T ZIP: $$ g Address; 3,14 o of !`A Ir A, Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits oorts) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Window(s) Repair Storm Damage 18202 Minnetonka Blvd Deephaven,MN 55391 ❑Siding ❑Restoration C(Other. (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Re-roof ❑Fire Damage mi nehaha eek.or Overall Project Description: Q n d a/� a CA /114 4 Estimated Construction Valuation of Pro act(excluding Ian ) $ O L APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all Information required or requested by the Building Department; Certifies that the Information supplied is true and correct to the best of his/her knowledge. The appiloant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative but to reject it until it Is complete; • some or all of the information that you are asked to provide on this application Is classified by State law as either private or confidential. Private data is Information which generally cannot be given to the public but can be given to the subject of the data. Confidential date is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. if you refuse to supply the information theapp ication ma not be issued. Applicant's Signature: -/�-� Date: ,--i nK nn--7nno