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CITY OF ORONO * 2 0 1 4 - 0 0 Z 6 7 *
2750 KELLEY PARKWAY DATE ISSUED: 04/04/2014
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 : WINDOWS
ACTTVITY : O/S BUILDING - UNDEFINED
VALUATION : $ 12,812.00
NOTE: REPLACE(2)WINDOWS AND(I)FRONT ENTRY DOOR
APPLICANT PERMIT FEE SCHEDULE 236.00
STATE SURCHARGE(VALUATION) 6.41
PELLA NORTHLAND MAIL-IN FEE 2.00
15300 25TH AVE N. - SUITE# ]00
PLYMOUTH, MN 55447 TOTAL 244.41
(952)345-6047 Payment(s)
Minnesota State License#: BUIL-BC645090 CHECK 67634 244.41
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 performed according to
the approved plans and specitications,applicable City approvals,and the
State E3uilding Code. This permit is for only the work described and docs
not�rant permission for additional or relatcd work which requires separate
permits. All provisions of laws and ordinances governing this type of work
shall be compied wi[h whether or not specified herein.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 I SO days at any time after work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be
revoked a[any time for due cause.
.
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Applieant Permitee Signature �te Iss d By Signature Date
ArRiC1���G�14/TUE 04; 28 AM Elder Jones Building FAX No, 952 854 4909 P, 002
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City of Orono
Bui[ding Permit App[ication for Internal Work
(windows, daors, siding, re4roofy etc.)
Mailir7g A�ldress: � Z 7
�,�,�. PO Box 66 Permit number: -
Yv CrystaE Bay, MN 55323-0066 Date received: —�
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"`�°,�'�,•- . Received by:
a 4'�7�,,-;'' a, 5trgef Address=
r�.� ,•.,,,�;,.-
'� y�.�°ti�''rM� ti 2750 Kelley Parkway Plan review fe
�R���S�oa��� Orono, MN 55356 � ����
Total Fee� .
Main: 952-2�i9-G600 Fax: 952-249-4616 :vww, i. r n .mn.us
� This application form rnust be complet�d in full and all required informatipn musT be submitted.
Incomplate applications wiU be returned. (Please print)
G�N�RAL lNFORMATION� � . � � �� �
Job Site Address:
Wil!this ba a I'arade of Womes, Remod�lers Showcase Home or other Dispfay Home? ❑ Yes No
!f}�es,a special event permit is raquired witn Pollce Department and City Council approva160 days prJor to the event. Shuttla bus servlce wi!!be
r�quired unless applicant demonstrates sufficienf on-site parking is avai/ab/e. Non�permitted events wi!!not be allow�ed.
GONTRAC7d}�/APPLICANT INFORMATION:
Name: 9'S.� 3y�•G q y,.7
State License# �e�la No�'t111a11d
�hone: 15300 2Sth A.�e N. Ste J.00 c�ll
Mailing Address: ____ P1�ni0uth,MN 55447 z�p-
Contact Person: Lic#BC645090 Ph. 763/745�1400 {�meowner (Circle one)
Email and/or Fax:
PROPERTY OWtV�R 1 ORM TION:
Name: ( C Q.C-�� � �
Phone{day): '� C �D . 7 ,,/ /
Address: 'Z /' 0 l..3 _ �� Q V City: �'��Q �Q C d ZIP: 'J�� s �+
T_ �
Email and/or F2x
PROJ�C7 INFORMATION:
7ype of ProJect Any earth movement may requlre
MCWD review&permits
^oar(s) � ❑ Remodel ❑Water Damage
Minnellaha Creek Watershed District(MCWO)
!�1`4�lindow(s) � �,] Repair ❑Storm Damage 18202 Minnetonka Blvd
Deephaven, MN 55391
❑Siding ❑ Restoration [� Other: (specify) Phone: 952,471-0590
Fax: 952-471-p682
❑ Re-roof ❑ Fire Damage www.minnehahacreek,or �
Overall Project Description: a �� �.,> >` d/� ��
Estimated Construction Vaivation af Project(excluding fand $
J
APPLiCANT ACKNOWLEDGEM�NT:
- Agrees to provide all infnrmatipn required or requested by the�Uilding Department;
. C�rtifces that the information suppli2d iS trUe and correct to the best of hiS/her�knowledge. The applicant r2GOg�iZ2S that they
are Soleiy responsible for submittir�g a complete application being aware thaf upon failura to do so, fhe staff has no alternalivR
but to reject it untif it is complete;
• Some o�aU of the Information that you are asked tb provide on this application is classified by State law as either private or
confidential. Private data is {nformatiof3 whiCh generally cannot be given tb the publiC bUt can be given to the SubjeCt Of thg
data. Confidential tlata is infOrmation which generally cannOt be glven t0 9ither the public or the sUbject of the data. Our
� purpose and intended use of this informafion is to annually update our records and records of other governmental agencies
re uired b law. I� ou refuse to suppl the information,the a liC2tion ma not be issued.
A [icanYs Si nature- � � Date: � � r �I�
PP 9 �
Lask Updated: 05-04-2009
AP�/Oi/�014/TUE 04: 28 AM Elder Jones Building FAX No, 952 8�4 4909 P, 001
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1120 East 80t°Street,Ste,#211;Bloomington,MN 55420 _
952-345-6047-Dir�ct 952-8�54-4909-Fax � � � �
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To: Orona, Gity of Attn: Bldg. Dep� From:
Fax: 952-249-4616 � Pages:
Phon�: 952-249�1600 Date:
Re: Building Permit(s) CC:
Cl Urgent ❑ �or M'teview ❑P[eas�Comment X Please Reply ❑Please Recycle
• Comments:
please call when the pe�rnit fee(s) ha�e been figures. Sa I can cut a check, _ , . , ,
Thank You,
�b�i
952�45�047
�y Ss�t -�t 90 q
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