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� Aug.�B, 2011 2: 23PM No. 7798 P. 1 <br /> Clty Of OI�OnO <br /> Building Permit Application for internai Work <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress, Permitnumber. ���'(�v <br /> O.¢,O�.O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a � `T e. Street Address: Received by; <br /> '��, ,� � � ��ti 2750 Kelley parlcway Plan review fee; <br /> �ao�.� , Orono,MN 55356 <br /> Total Fee: � , <br /> Main: 952-2a9�F600 Fax; 952-249�616 www.ci,orono.mn.us <br /> This application fo�m must be completed in full and all required information must be submitted. . <br /> Inccmplete appiications will be retumed. (Please prinf) <br /> GENERAL INFORMATION: . � � <br /> Job Site Address: �O�C O p c��, , � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes �No <br /> K yes,e speaial event peimit is required with Podce Departmenr and C;ty Council approva!60 days privr b the event Shuttle bus servlca will be <br /> required unless applicant demonstrdtes sufficient on-�te pai►dng is available. Nan-permifted evenfs wilf not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name; �j�,h,�� �,ro� <br /> State License# �o a.3�3<o q Expiration Date: 3 [1 <br /> Phone: ySa-,� �o C) office cell <br /> Mailing Address: I t��.sl � t� kitr (v . Ci : '� S ZIP: S 3 �/ <br /> • Contact Person: ,���}.�`"�,,���;c I,�; Applicant is: ontra / Nomeowner �circie oM� <br /> �mail and/or Fax; <br /> PROPERTY OWNER INFOwuI�►naN: <br /> Name: C_In v�S � }�ec�'��r I�o.�.l� <br /> Phone(day): 9S'�- �-( 7(n� �o 06 <br /> Address: ?,b loo Cs��w�. �cQ (Q ��Y�V'o n cJ � ZIP:S,5"�S�o <br /> Email and/or Fax <br /> PROJECT INFORNWTION: <br /> Type of ProJect: � Any earth movement may requlre <br /> MCWD review&permib <br /> ❑Door(s) ❑ Remodel �Water Damage <br /> Minnehaha Creek Watershed Districi(MCWD) <br /> '�Wrndow(s) ❑Repair ❑Storm Damage 19202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> ❑Siding ❑Restoration ❑Other.(specify) Phone: 952-471-0590 <br /> Fax: 952�i71-0682 <br /> ❑Re-roof ❑Fire Damage www.minnehahacreekorg <br /> Overall Project Descrlptlons �, ` n �.'�'.� ov'kS s- co+S il� Q, f�S ` v� o e►�i�c�,s:__„ <br /> Estimated Construction Valua�on of Project(excluding land) $ (�� ��_�_(Tt� <br /> — , . <br /> APP�icaNT ACEavow�EQGEMENT: <br /> . Agrees to provide all informaaon required or requested by the Building Department; <br /> . Certifies that the information supplied 'Is true and coRect to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> hut to rejed it until it is complete; <br /> � Some or all of the information that you are asked to provide on this application is dassified by State Iaw as either private or <br /> confidential, Private dat� is information which generally cannot be given to the public but can be given to the subjed of the <br /> data. Gonfidentia! data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use af this infonnstian is to annually update our r�ec9rds and records of other govemmental agencies <br /> � _ raquired b r�law. If you refuse to supplY the infoRnatlon,the dpplication may not be issued. <br /> ApplicanYs Signature: .��. w Date: �-�!� ' <br /> i��i�i..�+e►a.�• n�n��nno <br />