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20�1-0�=18 01 :49 GRUSSING 9529356514 » +9522494616 P 2/3 <br /> City of O�ono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) , <br /> ��.� Mailing Address: Permit number: <br /> O.g„j O,�O Po Box gs <br /> Crystal 9ay, MN 55323-0066 Da�te reoeived: ` <br /> 1 Str+eet Address: Reoeived by: <br /> � � �� 2750 Kelley Parkway P�an review fee: <br /> � _—�,�.�j Orono, MN SS3� <br /> '� Total Fee: � �'/ � � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.u.orono.mn.us <br /> This application form must be completed in full and all required information must be submitEed. <br /> Incomplete applications wil{be retumed. (Please printj <br /> GEPIEI�AL INFORMATION: � <br /> Job Site Address: �� ��S-f� ��,���'7� ���'� <br /> Will this b�a Parade of Homes, Remodeler�Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a spedal s►bnt pe►'mlt!s roqulrsd wrth Pofice Depertrne�and Cily Counal epprovel 80 deys pdor to die event. Shuttle bus service will be <br /> requireal unkss sppJleant demonabatas suPlicbnt on-site paAclnq is evalla6ls. Non-permltted events w/p not be aBowed. <br /> CONTRACTOR/APPR.ICANT INFORNAATION: <br /> Name: _- �s. �G, ,.�Z- � <br /> State License# ��f�,.� ,� � T—� Expiration Oate: <br /> Phone: G '_ �.r'�,�c:c^ office cell <br /> Mailing Address: �.�,-- C' : • ZIP: � <br /> Contact Person�« " ;' , !�,� Applicant is: Contra o�► / Homeowner �c�ra.oe•� <br /> Email a�d/or Fax: '-�13 � <br /> PROPEI�TY OWNER INFORMATION: <br /> Name: /'�i///i► �/%J%"�/ <br /> Phone(day): ��-�3"7- �- � . <br /> Address: !3!S �5f l�iv;f�e-ac_�-- Ciry: (�/rGh� ZIP: 5��'3��� <br /> Email andlor Fax <br /> PROJE T INFORMATION: <br /> Type of Project: Any earth movemtrrt may require <br /> ❑Door(� []Remodal MCWD review S permits <br /> ❑Water Damage <br /> Minnehaha Creek Watershed Disfiot(MCWD) <br /> p wnaow(s) ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑5idin Deephaven,MN 55391 <br /> g ❑Restoration ❑Other.(speafy) Phone: 952-471-0590 <br /> Fax: 952�71-0882 <br /> Re-roof ❑Fire Damage ` www.mirtnehahacrroek.qrq <br /> Overall pro ect Descrlptlon: <br /> EstimAteld Construction Valuation of P ect(excludin land) S (�,�, , 9 �� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> � l4orees to provids all irrformation required or requested by the Building Department; <br /> • Cenifles th�th@ information supplied is true end corre� to the best of his/her k�owledge. The applicant recognizes that they <br /> a�solely responsible for submitting a oomplete application being aware that upon failure to do so,the staff has no altemsUve <br /> bult to reject R until it is complote; <br /> • S�me or all of the information that you are asked to provide on this appliption is dassified by Staie law as either private or <br /> cdnfiderrtial. Private data is informabon which generally cannot be given to the public but can be given to the subject of ihe <br /> data. Corrfidential data is infomiation which generally cannot be glven to either the public or the aubject of the data. Our <br /> purpose and intended use of ihis ir�formatio� is to �nnually update our records and reowds of other govemmental egencies <br /> _ reguired by law. If ou refuse to su I the information the� lication ma not be Issued. <br /> Applicant's Signatur@; oate: 1 ! <br /> � � • � <br /> last uodatect os-w-�nnq y <br />