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' CITY OF ORONO PERm�T �vo.: 2010-olis�
2750 KELLEY PARKWAY
ORONO, MN 55356- DATE ISSUED: 12/2U2010
952 249-4600 FAX: 952 249-4616
ADDRESS : 2565 COUNTRYSIDE DR
PlN : 04-117-23-11-OOlI
LEGAL DESC : COUNTRYSIDE MANOR 2ND ADDN
: LOT 001 BLOCK 003
PERMIT TYPE : MINOR ALTERATIONS
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : DOORS
ACTIVITY : O/S BUILDING - UNDEFINED
VALUATION : $ 3,452.00
NOTG: RGPLACG(1)DOOR Wf"CIIIN EXIS7�ING OPLNINGS.
APPLICANT PERMIT FEE SCHEDULE ]03.25
RENEWAL BY ANDERSON STATE SURCHARGE(VALUATION) 5.00
1920 COUNTY RD C. WEST
ROSEVILLE, MN 55113 MAIL-IN FEE 2.00
(612)502-4777 TOTAL 1 10.25
Minnesota State License#: 20130983
OWNER
MICH, MR. c� MRS.
2565 COUNTRYSIDE DR
LONG LAKE, MN 55356-
AGREEMENT A[YD SWORN STATEMENT
Thc�cork for���hich this pennit is issued shall be perfonncd according to
thc approved plans and speci�ications,applicable City approvals,and the
State Building Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separalc
permits. All provisions of laws and ordinances governing tl�is t��pe of�cork
shall be compied�cith�cheU�er or not speeitied herein.This permit will
expire and become null and void if construction authorized is not
commenced���ithin 180 da��s of the date of issuance,or if construction is
suspended for a period of I 80 days at any time alter���ork has commenced.
The applicant is responsiblc for assuring all required inspections are
requcsted in confonnance with the State Building Code.This permit may be
revoked at any time for due.cause.
��1'1'Q�[� �' l l ��i�l't—��/� l l
Applicant Permitee Signature Date Issued L3 � ignature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABO
Dar-08-2D10 01:58pm From-CITY OF ORONO +8522494616 T-669 P 003/003 F-160
- -� - - : . �..� i
` Building Permit Application for Internal Work
(windows, doore, s�ding, re-roof, etc.
O�O� MeMng Address:
PO eox 66 Permlt number: o�0lD— O
Q Crystal 8ay,MN 86323-Op66 Dat�e reCenred: / �' /zj
� � SfngAt Aadr+ess: ReCel�eu by�
2750 Kelley Parkway �
�t� �' Orono, MN 55356 Plan revlew fee: '
Main: 952_249-4800 Fex; 952-249-4B1B bpdp�,c}�drono.mn ua 7�1 Fee: ��D,�
7his application f�rm must be completed in full and all requi�ed intorrnativn must be submitted.
Incomplete applicatlons wlll b�retumed. (P/ease print)
(3ENERAL INFORIAATION: �� � COUn'�(
Job 31te Address: �CJ� �� ��
Wlll thi8 be a Par�de of Hornes, Remod�lers Showcase Hom� or other Display Home? Yss No
7Ya�,e apecie/everu pe�n�t Js�equ1►sd wwrrhh►oi;ce n•pann+er��and c�ty Counc�i•ppruve�e0 aeya prror ro rne ovenc Shub�e bus�e,vrce wra ea
r�qu�red wleas apprlcenf domonet�s auificiant on•ei�per(cMp ie avell�dle. Non-pennlfled aya�f8 wil/�p160 ellowsd.
CONTRACTOR/APPLICANT INFORMATIpN;
Name: Renewal By Andersen
P otne:��nse # 1920 County Road "C" West Exp�ratfon C)ate:
Mailing Address: Rosevilte, NfN 551 l3 C� , cell�
Contact Person: License #20130983 z►P;
Email and/or Fax: �` 6S l-264-4777 �t is: Contractor / Homeowner �c►K�s o�.�
� �
PROPER7Y OWNER INFQ ION:
Name: � ����
Phone(day): _
Address: I CI :
Emall andlor Fax 21p�
PROJECT tNFORMATION: ` �
Typs of ProJect "� . � •
An art rr�oveme ay requi� ,
i ❑Door(s) ❑ Remodel ❑Weter Damage MCWD�vlew 8 pernlibl
,
CI Window(s) ❑ Rapair Mlnnehehe Creek Waterghed Distdct(M WD)
❑ Storm Damage 1 B2e)2 M�nnetonka elvd
❑ Sltling []RestoraGon D�'BPhaven,MN 56391
❑Oth�r:(r,peCify) Phane; 852�71-059d
❑ Ra-roof � ❑Fire bamage Fsz: 852�71-0682
Overoll Pro ect Descrf tlon:
EBtlmated Constructlon Veluation of pro ec!(oxaludin I�nd) s a
APPLICANT ACKNOWLEDGEMENT: �
• Aprees to provfde all informailon raquired or requested by the 9uflding oapedment;
• Certifie� that the InfCrmatlon suppNed ie true and corrett to the besl of hisfier knowiedge. 1'he opplioani rewgnizas that they
ere solely reaponaibie for aubmlttin0 a complete applicatlon being awate that upon i�llure to do so, the sta}f hae no altemative
but to reJgCt il uMil it i�complete;
• 8ome or atl oi the intormatlon that you a�e aaked to prov�de on this applicetlon is clessified by 6t8te law as elther private or
cAnFdential. Private deta is informatian whlch generelly cannot be givan to fhe publ� but can be glven to 1he subject of t1�a
data. Confldentie! darta f� Informatio� which gener�lly cannOt be glvBn to either tlte public or tha subjed oi the date. Our
purpose and intended u8e vi thts informallon ia to gnnually updete our records and /8cord:+ of olher govemmerttal agencie�
re ulred b leW, N 0�refuae to su ! the informatian the a Ilcation ma nof be Issued.
4pplicant's Si9natu�e� I�'��J ,�l
08te: f(J
.e6t Updated: 05�44-2009
1
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� � �I C � _DATE TIME ✓
CITY�F ORONO 1CALlED IN �--� Z� � �
—�— ,
INSPECTION NOTICE_ �. -� SCHEDULED __`�2� T
PERMIT NO? C��l�r � C �(� � cornP�ETEo
ADDRESS �c�U' � � �' l . ��-�t1.�'� i C�e l�f�
OWNER TELEPHONE NQ.� �'S� ��'`� yi��
CONTRACTOR ���� ��%«--
� DESCRIPTION
� ( �l��a / ��C'c f l c /�C c` (< /�i"y,�,
�
� ❑ FOOTING ❑ PLUMBING FINAL ❑ EXCAV/GRADING/FILLING
Q ❑ POURED WALL ❑ MECHANICAL RI ❑ LAKESHORE/WETLANDS
y ❑ FRAMING ❑ MECHANICAL FINAL
O ❑ TREE REMOVAL
Z ❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ SITE INSPECTION
Q ❑ RADON SLAB ❑ WATER HOOK-UP ❑ PROGRESS
� ❑ FINAL ❑ SEWER HOOK-UP ❑ COMPLAINT
v ❑ DEMO-SITE ❑ SEPTIC MAINT. ❑ FOLLOW-UP
_ ❑ DEMO-FINAL ❑ SEPTIC INSTALL ❑ HARD COVER REMOVAL
J ❑ PLUMBING RI ❑ SEPTIC FINAL ❑ FOUNDATION/REMOVAL
� OWNER/CONTRACTOR TO MEET YOU:_YES�NO
� COMMENTS: /
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� ❑WORK SATISFACTORY:PROCEED j�AROJECT COMPLETE
W ❑CORRECT WORK&PROCEED l0 ISSUE CERTIFICATE OF OCCUPANCY
� ❑ CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
� BEFORE COVERING PERMANENT
❑CORRECTUNSAFECONDITIONWITHIN HOURS. � pHOTOTAKEN
INSPECTOR WILL RETURN
❑STOP ORDER POSTED.CALL INSPECTOR � CITATION ISSUED
❑ INSPECTION REOUIRED.CALLTO ARRANGE ACCESS.
Cail for the next inspection 2a hours in advance. (952� 249-4600
OwnerlContractor on site:
Inspector. `�-� � �C
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