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10/05/2010 10:25 6512510916 WALKER ROOFING PAGE 02 <br /> r A► <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: '3 aio GYM 9/9 <br /> (').49- ------=---4:3-41)4 f PO Box 66 <br /> Crystal Bay,MN 55323.0066 Date received: /D/Jr//711 St eef Address: Received by:''i� ' 2750 Kell Parkway lit Orono,MN 55356 Plan review fee: <br /> Total Fee: 1 /8/ ,e <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci,orono,mn.us 'j <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: <br /> Job Slte Address: LI-70 OLP L iy4 LJ c (?.o <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? [] Yes il2No <br /> if yes,a special event permit is required with Police Department and City Council approval 50 days prior to the ovent. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-alto parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: WALKF Rnnct, • , <br /> State License VI WESTWAY EXTERIORS INC Z' Expiration Date: _341142.4t,II, <br /> Phone: " " • 4 (office) ubSl�'���i—d •lId (cell) <br /> Mailing Address: Ci : ZIP: <br /> Contact Person: , , Applicant is: ontra or Homeowner (Circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: P66/4[+(6 l TSos.) <br /> Phone(day): q_.52- 2.3'1-41 1 <br /> Address: q7( OLD Lori(( Lor 6 'gyO City: 0j2.0/1JO ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) Remodel MCWD review&permits <br /> rO ❑ ❑Water Damage <br /> ❑ Repair El Storm Damage Minnehaha 6 02 Minnetonka Blvd <br /> eek Watershed ct(MCWD) <br /> ❑Window(s) <br /> Deephaven,MN 55391 <br /> ❑Siding ❑Restoration 0 Other:(specify) Phone: 952-471-0590 <br /> Re-roof Fax: 952.471-0682 <br /> I <br /> ❑Fire Damage www.minnehahaoreek.orq <br /> — <br /> Overall Project Description: ' Ef j1.E�Q a MouSE' D C , <br /> Estimated Construction Valuation of Proje (excluding land) $ 'Lq t I 90, 211 <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 date 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 /> re•uired b law. If ou refuse to su•.1 a information,the a•plicatlon may not be issued. <br /> )IIIIr4 ' <br /> IO/c QApplicants Signature: [lir Date; v lb <br /> I <br /> Last Updated: 05-04-2009 <br />