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City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> 0� <br /> �0 Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Y �8 <br /> 1• Received by: <br /> f , �, Street Address: <br /> tis 2750 Kelley Parkway Plan review fee: <br /> og�G Orono, MN 55356 <br /> ESH <br /> Total Fee: <br /> Main: 952-249-4600 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 returned. (Please print) <br /> GENERAL INFORMATION: v'? `J No f4h 9,47LG 15 0 Q 61 <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> !f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: J O d, 4) EIeetP JOAN t <br /> Name: <br /> State License# Pella Windows &Doors Q'S 213 46 - s y 7 <br /> Phone: 15300 25th Ave N. Ste 100 (cell) <br /> Mailing Address: Plymouth, MN 55447 ZIP: <br /> Contact Person: Lic#20165884 Ph. 763/745-1400 lomeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: I/ <br /> Name: D r n 0 l G/ <br /> Phone(day): G 1 o2l Vf, ,( - -7 Y -1 ./ S S 39 / <br /> Address: -,26 -6 r 4 ACi /�0 O ZIP: <br /> Email and/or Fax G /.2 4 - '7 <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> 0 Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> [�44/indow(s) [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 www.minnehahacreek.org <br /> Overall Project Description: LAI A CrO GJ 0A �YZ S A, <br /> Estimated Construction Valuation of Project(excludi g land) $ 41 j <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 classed 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 application may not be issued. <br /> Applicant's Signature: Date: <br /> tZ <br /> Last Updated: 05-04-2009 <br />