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CITY OF ORONO * z 0 1 4 - 0 1 1 4 5 *
2750 KELLEY PARKWAY DATE ISSUED: 10/07/2014
ORONO,MN 55356-
952) 249-4600 FAX: 952 249-4616
ADDRESS : 855 PARTENWOOD LA
PIN : OS-117-23-34-0012
LEGAL DESC : PARTENWOOD
: LOT 005 BLOCK 002 �
PERMIT TYPE : MINOR ALTERATIONS
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : WINDOWS
ACTIVITY : O/S BUILDING-UNDEFINED
VALUATION : $ 31,000.00
NOTE: (10)WINDOWS AND(2)ENTRY DOOR REPLACEMENTS
APPLICANT PERMIT FEE SCHEDULE 477.50
STATE SURCHARGE(VALUATION) 15.50
PELLA NORTHLAND MAIL-IN FEE 2.00
15300 25TH AVE N. - SUITE# 100
PLYMOUTH, MN 55447 TOTAL 495.00
(952)345-6047 Payment(s)
Minnesota State License#: BUIL-BC645090 CHECK 69366 495.00
OWNER
GUL, SHAIKH ASIM
855 PARTENWOOD LA
LONG LAKE, MN 55356-
AGREEMENT AND SWORN STATEMENT
The work for which this pertnit is issued shall be performed according to
the approved plans and specifications,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 separate
permits. All provisions of laws and ordinances goveming this type of work
shall be compied with 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 180 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 at any time for due cause.
C � �� �o / � l �
Applicant Permitee Signa ate Issue By Signature Date
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City of Orono
Building Permit Application for Internal Work
(windows, doors, siding, re-roof, etc.)
Mailing Address: Permit number: D� - /
ji�Q� PO Box 66
Crystal Bay, MN 55323-0066 Date received: _f0'7�
O ��. O Received by:
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a ��'��`i��;,;;_ �, Street Address:
� {'r,`p titi 2750 Kelley Parkway Plan review fee:
�`'l��l y��{�`►�"�° Orono, MN 55356 ,�^
9kESH� 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:Q � �, nQ � � � � O „/ / Q � �
Job Site Address: Z3 t� u l..
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
required unless applicant demonstrates su�cient on-site parking is available. Non-permifted events wil/not be allowed.
CONTRACTOR/APPLICANT INFORMATION: 9 S A�3 SI S •L n y 7
Name: Pella Northland n di
State License#
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 I ORMATION: >
Name: I �Cl I
Phone (day): 9 3
Address: , Q� !1 L✓ !�i d Cit : � � � n v ziP: 5 5 3 5 �
Email and/or Fax
PROJECT INFORMATION:
Type of Project: Any earth movement may require
MCWD review&permits
Door(s) ❑ Remodel ❑Water Damage
Minnehaha Creek Watershed District(MCWD)
�Window(s) epair ❑ 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:/p �„� � 1 � e � n
Estimated Construction Valuation of Project(excluding land) $ 3 / � 0 O
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 generatly 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.
Applicant's Signature: �✓` Date: l o [ ( L � /
Last Updated: 05-04-2009