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Jun-07-2010 07:19am From-CITY OF ORONO +9522494616 T-287 P.002/003 F-187 <br /> Building Permit.Application for Internal Work <br /> (windows, doors, siding', re-roof, etc.) <br /> Mailing Address:, Permit number: ,2.016, -6 6 4.Z5 <br /> 0�°`P-) PO Sox 66.Crystal Bays MN 55323-0088 Date received: <br /> vfil� <br /> I- <br /> j. � <br /> Street Address: i Received by: � <br /> � � .r 2750 Kelley Parkway Plan review fee: /11/4 <br /> i,'102,' Orono, MN 55356 <br /> Total Fee: ii, aZ z,66 <br /> Main: 952-249-4600 Fax: 9552-240.46113 • www.ci.orono.nm.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete application milli be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Sits Address: 1535 6'(c%mnstl efecAckTka - <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? 0 Yes 0 No <br /> If As,a amass event psnn/f le rewired with Polies nt ern City Council approval e0 days prior so me event. Shut*bus service wilt be <br /> ,equbed unless applicant deatOnsiraMs auArclnt mote perianths available. hltopemtitted every will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: Renewal By Andersen <br /> State License# 1920 County Road "C" West` Expiration Date: <br /> Phone: Roseville,MN 55113 ______,___________t_) <br /> _ell <br /> Address: City: ZIP: <br /> Contact Person: License#20130983 ,t Is: Contractor / Homeowner (Circleorwt <br /> Email and/or Fax: 651-264-4777 , <br /> PROPERTY OWNER INFORMATION. <br /> Name: NCL" DE 1+0Y1 - <br /> Phone(day): 95 - -- = — • S <br /> Address: ^ City: _ ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: • <br /> Tyle of PreJeet: 1 C.2 1 p cx,-K Cy do1)i✓1 Any earth movement may require <br /> �,c�}� INCWD review+#permits <br /> ❑Door(s) O�&� '"' Water Damage <br /> �A0A1 Minnehaha Creek Watershed District(MCWD) <br /> ❑1Mndow(s) Cl Repair "�— ❑Storm Damage 18202 Minnetonka Blvd <br /> . Deephsnren,MN 85961 <br /> 13 Siding 0 Restoration p other:(speclfy�; Phone: 9132-471-0590 <br /> Fax: 952471-0882 <br /> In Re-roof 0 Fire Damage • www,minnehahacreek.orp <br /> Overall Project Description: , <br /> Estimated Construction Valustlon of Project jezcluding land) $ r-J i Ji 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 beat of his/her knowledge. The applicant recognizes that they <br /> are solely responsible far 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 /> date. 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 supp the Information,the application may not be Issued. <br /> • <br /> Applicant's Signature: ! 1 t%!'‘, J Date: 49 (iiN--Q lb <br /> • <br /> Last Updated. 05-04-2009 <br /> g•d O6T9bL9Tt:9 3DIA213S IIWt13d U B S R Sis: TT OTOS CO unr <br />