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JUN/25/2015/THU 04: 56 AM Elder Jones Building FAX No, 952 854 4909 P, 002 <br /> . ,. . <br /> City of Qrono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> ,�,,—� Malling Address: Permit number_ – QQ <br /> �-�v�.� PO 6ox 66 . <br /> ' CrystaE Bay, MN 55323-0086 Date received: <br /> �� `,.. d � _ <br /> r �����.,,., <br /> a '°'���.: �. SCreet Address: Received by: <br /> �..��.. <br /> �a, �"�,�, �ti 2750 Kelley l�arkway Plan review f • <br /> �'�i�`�?�'� �.9 Orono, MN 55356 <br /> '�$9Y�0 . <br /> �"`.``� Total Fee. l7� �I <br /> Main: 952-249-A�600 Fax: 952-249,4616 www.ci.oronQ,mn.us 1 <br /> This application form must be completed in fuA and all required informatiqn must be submitted. <br /> Incomplete appiications will be retumed. (Please print) <br /> C7ENERAL 1NFORMATfON.' l p <br /> Job Site Address: l� Q � �a �T r Q � � 0 <br /> Wifl this be a Parade o'F Hbmes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> N yes,a spaclal ev�nf permit is requlred wlth Po/iea Department and City Councll approva/80 days prior to tha event. Shun/e bus service wil!be <br /> �squired un/ass epp�icant demonstrates suh3cienP on-s;fe parking is avallab/s. Non-perm,Yted events will not be allowed. <br /> � CONTRACTQR!APF'�I�ANT IIVFORMATION; <br /> Name: � 2 �, �d <br /> State License# �'�TD At-Home Service, Inc, <br /> Phone: 2690 Ct�.mberl�,xnd Pkwy, Ste 300 cell <br /> Mailing Address: A.tla,nta,GrA 30339�3913 ZIP: <br /> Contact Person_ Lic#CR268257 Ph. 763/542-8$26 lomeowner �c�21a o�a� <br /> Email and/or Fax: <br /> PROPERTY OWN�F�INFORMA7'�QN: <br /> fVame: LJ I't b,,f t7((,� Q <br /> Phone(day)� /� 7 0 - 3l a y <br /> Address: � b j� /QQ c; : C9/`o/? a ZIP: S�L <br /> Email ancllor Fax <br /> PROJECT INFORMATION: - - <br /> Type of Praject: Any earth mOVement may reyuire <br /> � MCWD review&permits <br /> '�Door(s) ❑ Remodel [J Water Damage <br /> Minnehahl Creek Watershed District(MCWD) <br /> indow(S) []Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding „ [J Restoration ❑Qther:(specify) Phone: 952-471�A590 <br /> Fax: 952-479-0682 <br /> ❑Re-roof ❑ Fire Damage www.tninnehahacreek.ora <br /> qverall Project Description: /W i11 p I�f • � . i� �(q n r /�e B �'/� ! ! y 1�� �' 0 .!!I /n� <br /> Estimated Construction Vatuation of Project(excluding land) $ L <br /> , <br /> APPLICANT AGKNOWL�DGEMENT: � <br /> • Agrees to provide alf information required or requested by the Building Department; <br /> • CertifJes that the information suppfigd is t1'ue&nd correct to the best of his/her know(edge. The appEicant recpgnizes ChBt they <br /> • a�2 Solely responsible for submitting a Complete application b�ing awar@ that upon failure to do so,th9 StBff haS f10 altemative <br /> bvt to reject it until it is complete; — <br /> • Some or all of th� infOrrrtati0n that you are asked t0 p1"Ovlde Oft tf1i5 application is classified by State law as either privafe or <br /> confidential. Private data is inform�ti0n whieh generally cannot be given fo the public buf can be given to the subject of ihe <br /> data. Confidentiaf data is information which ganerally cannot be given to either the publie or the subject of the data. �ur <br /> purpose and intended use of this informatiort is to annualEq update our records and records of other governmenta! agencies <br /> re uired b law, lf ou refuse Eo su I th�inform�tion,the a fication ma not be issued. <br /> � �, �72 �IS <br /> AppEicanYs Signature: Date: <br /> Last Updated: 05-Od-2008 '. <br />