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<br /> L Building Permit Appiication for internal Vlfork
<br /> (windows, doors, siding, re-roof, etc.) �- ���7'3�'
<br /> Mailing Address: Permit number: ,�D/6 ���� '�j'�
<br /> �j,�,�. PO Box 66
<br /> O �\ O 1 Crystal Bay, MN 55323-0066 Date received: / J� ,Zdl�
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<br /> ,� �'�h�J� '�' �,J StreetAddress: rieceived 'oy:
<br /> �� �^� � n
<br /> �',F, ��� ♦,^ Gti 2750 Kelley Parkway Plan revie fee: � C/
<br /> L9kE3H 4� Orono, MN 55356 �7��('�Od t/
<br /> Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �/j� �, t�,�r ,�,�.
<br /> �.�t,�t.��r�:..,':;c;�yn
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No
<br /> If yes,a special event permit is required with Police Deparfinent and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is availsble. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �7sr���.rz !��'���r�a�-��nn.��..
<br /> State License# '� 7,a.,� Expiration Date: -� -�/-/p
<br /> Phone: q�z- y?s -��`3�,' (office) ,;,r:-yi� - �/: �� (cell)
<br /> Mailing Address: t K.3�en y��-r-�� 3,..v�� City,;._;,,.�1,�•.��w� ZIP: �.�s�-'�/
<br /> Contact Person: ��.,�v� Applicant is,�'° Contractor�/ Homeowner (Circle One) '
<br /> Email and/or Fax: '""�"-��-
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ����vr5 cr !1�5r�� G+-,� ,�s�r�+����
<br /> Phone (day):
<br /> Address: �I�, � _ ;;'�.:s c��:��^. �.�,a�r7 ;��r^,.�u�'z. City: Ci�a .x:!� ZIP:
<br /> Email and/or Fax
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> MCWD review&permits
<br /> ❑ Door(s) �Remodel ❑Water Damage
<br /> Minnehaha Creek Watershed District;MCIND)
<br /> ❑ Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orq
<br /> Overall Project Description:
<br /> Estimated Construction Valuation of Project(excluding land) $ �� �� 'bd�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the information supplied is true and correct 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 alternative
<br /> but to reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies
<br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued.
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<br /> ApplicanYs Signature: r�_,�fi' �� ,<.-,,,__;,;7 Date: 1 —�— / �l
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<br /> Last Updated: 05-04-2009
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