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09/08/2009 03: 00 7632631004 DAN NETKO EXTERIORS PAGE 01 <br /> .I <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) _ <br /> Mailing Address_ Permit number: 2Ocq.- ,( S <br /> V.lO 4 PO Box 66 q <br /> Crystal Bay, MN 55323-0066 Date received: /9) C9 <br /> 0J <br /> ` Street Address: Received by: <br /> ill .: 2750 Kelley Parkway Plan review fee: <br /> i 1i�. Orono, MN 55358 <br /> __ Total Fee: f <br /> Main; 952-249-4600 Fax: 952-249-4616 www,ct.or no.rpp us 0 �'� _ <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: 106 <br /> � � 0�� C ,� ro , <br /> Job Site Address: ICA <br /> Will this be a Parade of Homes, Remodelers Showcase me or other Display Home? Yes No <br /> If yes,a specie/event permit is required with Police Department and City Council approval 60 days prior to the event. Snuffle bus service ill <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP- !CANT NFORMA ION: <br /> Name: 7110.4.t ,__s ' brS <br /> State License# a-11 ,• ' Expiration Date: 63 i 8 <br /> Phone: • office , l ) ;-• , ! cell <br /> Mailing Address: �',^ 1 ,�i Eri 5 ' Cit : ft__, _6. . . ZIP: S 3 0• <br /> Contact Person; �'>�i N_g,k14, Applicant is: figiariO / omeuwner prole one) <br /> Email and/or Fax: Yee-i-ice (i fin -4,..5_, Y1Q* <br /> PROPERTY OWNER FOR T1ON: <br /> Name: a r 61(46-114,,\ <br /> Phone(day): <br /> Address: � � _ City: ZIP: <br /> Email and/or Fax '1 <br /> PROJECT INFORMATION: /' "o\ <br /> Type of Project: l; <br /> 0 Door(s) in Remodel ❑Water Damage <br /> i / l) <br /> ❑Window(s) ❑ Repair 0 Storm Damage <br /> 12Siding 0 Restoration ❑Other: (specify) /{ (kw), f‘,. <br /> ,„, ,, <br /> Re-roof ( ❑ Fire Damage <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) t <br /> APPLICANT ACKNOWLEDGEMENT: � <br /> • Agrees to provide all information required or requested by the Buildi 1 <br /> • Certifies that the information supplied is true and correct to the be rt they <br /> are solely responsible for submitting a complete application being awcw. ,..o, ..r.... ._.._._ ._ __ __, _ 'native <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 generaly 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: 9tQA-_--' }���" _ ` ) Date: g( 1/0 7 <br />