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MAY/10/2013/FRI 04:07 AM FAX No. 952 854 490911, ,' P. 002 <br /> City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing ng Addox ress: <br /> . Permit number: pZ O J 3.5034g <br /> gc,, <br /> Crystal Bay MN 55323-0066 Date received: - 51'1/4i „ <br /> :,1•;w,,. y Received by: <br /> Street Address: <br /> 9 �fc' "rI 2750 Kelley Parkway Plan review fee: <br /> \; 91 tY �{ -41 Orono, MN 55356 <br /> ��.s�o Total Fee; 10.S 4 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono•n?n•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: to 0 �r.a O /,C h �• R0 Cr eJob Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? • Yes ■ No <br /> If yes,a special even!permit is required with Police Department and City Council approval 80 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. Jed/ <br /> CONTRACTOR/APPLICANT INFORMATION: JSa /3Ys•�yb�7 ' <br /> Same: Pella Northland <br /> State License# <br /> Phone: 15300 25th Ave N. Ste 100 (cell) <br /> Mailing Address: Plymouth,MN 55447 ZIP: <br /> Contact Person: Lie#BC645090 Ph. 763/745-1400 lorneowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: hilt <br /> Name: 0 r <br /> Phone(day): Q S? 2/ 0 . 7 3 3 3 <br /> Address: 1. 0 Ofe Ad oreAtttjj Re City: G/ay76-eQ ZIP: c S 3 ? / <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project! _ Any earth movement may require <br /> MCWD review&permits <br /> NISQoor(s) El Remodel ❑`Nater Damage Minnehaha Creek Watershed District(MCWD) <br /> a Window(s) " Repair 0 Storm Damage 18202 Minnetonka alvd <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.0rq <br /> Overall Project Description: 2 (A ry 0 .2 $ 0/'M A oaf Pop,p 4 a m l 4 S <br /> Estimated Construction Valuation of Project(excluding land) $ 7 / 2 I <br /> _ <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 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 /> rewired b law, If ou refuse to sup•I the information,the a.plication ma not be issued. <br /> 7 (!o <br /> l/3 <br /> Applicant's Signature: <br /> � Date: <br /> Last Updated: 05-04-2009 i�C <br />