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CITY OF ORONO * Z 0 1 4 - PJ 1 4 1 9 *
2750 KF.LLEY PARKWAY DATE ISSUED: 12/1U2014
ORONO, MN 55356-
� (952) 249-4600 FAX: (952) 249-4616
ADDRESS : 25 BROWN RD S
PIN : 03-117-23-21-0001
LEGAL DESC : UNPLATTED 03 1 17 23
: LOT 000 BLOCK 000
PERMIT TYPE : MINOR ALTERATIONS
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : WINDQWS
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VALUATION :C�� 20,645.0�
NO'I�E: (4)WINDOWS AND(l)ENTRY DOOR RF,PLnCEMEN'I�
APPLICANT PERMIT FEE SCHEDULE 354.00
STATE SURCHARGE(VALUATION) ]0.31
PELLA NORTHLAND MAIL-IN FEE 2.00
15300 25TH AVE N. - SU[TE# 100
PLYMOUTH, MN 55447 TOTAL 366.31
(952)345-6047 Payment(s)
Minnesota State License�#: BUIL-BC645090 CHECK 69943 366.31
OWNER
OTTO;MICHAEL
25 BROWN RD S
LONG LAKE, MN 55356-
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be perfonned according to
the approved plans and specifications,applicable City approvals,and Ihe
Statc E3uilding Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separate
pennits. All provisions of laws and ordinances governing this type of work
shall be compied wilh whether or not specified hercin.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
"I'he applicant is responsible for assuring all required inspections are
rcqucsted in confom�ance with thc State Building Code.This permit may bc
revoked at any time for due cause.
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Applicant Pennitee Signatur Date Iss By Signature Date
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City of Orono : �'�i4
Buiiding Permit Application for Internal Work
(windows, doors, siding, re-roof, etc.)
-- Mailing Address: Permit number:
Q_ PO Box 66
/� � � Crystal Bay, MN 55323-0066 Date received:
��� � Received by:
``� �����,•� �u� ti Stre 2 50 Kelley Parkway Plan review fee:
�\.� ���a; ��i�r;���. o ,
�,l �Il,i,�� sv,;� Orono, MN 55356
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��____= Total Fee:
Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
This application form must be completed in full and all required information must be submitted.
Incomplete applications will be returned. (Please print)
GENERAL INFORMATION: p -/ ��
Job Site Address: � �'j � ('o CJ � 1Z O Q' C� � 0 V
Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
If 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
requned unless applicant demonstrates sufficient on-site parking is availa6le. Non-permitted events will not be al/owed.
CONTRACTOR/APPLICANT INFORMATION:
Name: QS2 3yS• GnL17
State �icense# Pella Northland
Phone: 15300 25th Ave N. Ste 100 (cell)
Mailing Address: Plymouth, MN 55447 ZIP:
Contact Person: Lic# BC645090 Ph. 763/745-1400 �omeowner (Circle One)
Email and/or Fax:
PROPERTY OWNER INFORMATION:
Name: � t C h 0 Q,l d ��
Phone (day): �I S'2 0 0 • � �
Address: � 5 C o 4r�� •z � u c'� �� ::�� ��+�� v r o n O ZIP: S 5 3 5 �
Email and/or Fax
PROJECT INFORMATION:
Type of Project: Any earth movement may require
MCWD review&permits
Door(s) ❑ R2model ❑Water Damage
Minnehaha Creek Watershed District(MCWD)
Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
Deephaven, MN 55391
❑ Siding ❑ Restoration ❑ Other: {specify) Phone: 952-471-0590
Fax: 952-471-0682
❑ Re-roof ❑ Fire Damage www minnehahacreek.orq
Overall Project Description: �V �' /� 0 D �' � S
Estimated Construction Valuation of Project (excluding land) �Q G � 3
APPLICANT ACKNOWLEDGEMENT:
. Agrees to provide all information required or requested by the Building Department;
. Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they
are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
but to reject it until it is complete;
• Some or all of the information that you are asked to provide on this application is classified by State law as either private or
confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the
data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
purpose and intended use of this information is to annually update our records and records of other governmental agencies
re uired b law. If ou refuse to su I the information,the a lication ma not be issued.
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ApplicanYs Signature: � v Date:
Last Updated: 05-04-2009