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67126/2'011 15:03 9528885554 PAGE 01 <br /> , <br /> Gifiy of Orona <br /> Building Perm�t Applicat�on for Internal INork <br /> (windows, doors, siding, re-roof, etc.) <br /> /Q Mailing Address: Permit number: � � ' � � � <br /> � .�\ PQ Box 66 <br /> � � Crystal 6ay,MN 55323-0068 tiate received: � <br /> � � 5lreet Address: Received by: <br /> �+ ' � 2750 Kelley Parkway Plan review fee: <br /> ���Ko4'�' Orono, MN 55356 � �' �� <br /> Total�ee: � <br /> Main; 952-249�600 Fax� 952-249-�616 www,ti.orono.mn.i�� <br /> This appllcation form must bo completed in full and all required information musf be submitted. <br /> Incomplete appfications w(II be raturned. (P/ease print) <br /> GEN�RAL INFORMATION: <br /> Job Site Addr�ss; ��Q <br /> Will this be a Parade of Homes, Remodalers Showcase Wome or other Display Hvme? Yes No <br /> If yas,a special event permit is required wMh Polrca Depariment and Crty Council approval BO days pnor tn the event. Shuffle bus seror�wj►!bct <br /> required unless sppf;cant demonsfrafes suffrcient on-slle parkinq is evailable, Non parmr'tfied evenfs wN!not bo alfowad. <br /> �ONTRACTOR!APPUCANT INFORMATION; <br /> Name: � � <br /> State License# ' p " Expiration Date: ,3/_ <br /> Lead Certification Number: �Q ������ Expiration Date: �_ ��� <br /> (for work on homes that were consfructed p�ior to 9978 <br /> Phone: S - — (office) ��`/ /� 3�a�..�� (cell) <br /> Mailing Address: po� ,� �, r�f�ity: . ,�, ZIP: s- <br /> Contact Pe�son; �}e J � Wl� 1��,�^ A plicant is: Contracto ! Homeowner �ci��i.o�a� <br /> Email and/o�Fax; LW <br /> PROPERTY OVWNER INFORMATION: � ��� ���' ��l � ��� <br /> Name: �r �.�r�e.�,,, _ � C— �/1 <br /> Phone(day): ! a, / `�.��L�� <br /> Address: _�'�� City ZIP: <br /> Email andlor Fax <br /> PRQdECT INFORMATION: <br /> Type of Project: Any earth movement may requlre <br /> ❑ Door(s) ❑ Remodel ❑Water Damege MCWD revlew&permlts: <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Window(s) ❑ Repair ❑Storm Damage 18202 Minnotonka elvd <br /> Dee haven.MN 55391 <br /> ❑Siding ❑ Restoration []Other; (speCify) Ph ne; 952-071-0590 <br /> �Re-roof ❑ Fire Damage Fax: 952-471-0687. <br /> www.minnehahacreek.ora <br /> Overall Project Description: 'T p <br /> Estimated Construction Valuati n of Project� uding land) $ � 9�p , a c� <br /> APPLICANT ACKNOWLEDGEMENT; <br /> . Agrees 10 provido all information required or requested by the 8uilding Department; <br /> • Certifias that the information supplled is true and correct to the best of hlslher knowledge_ The appllcant recognizes that they <br /> ara solely responsible for submitting a complete application being aware that upon fa;lure to do so, the staff has no al�ernative <br /> but to reject it untll!t IS complete; <br /> • Sorne or all of the informatlon that you aro asked to provide on this applicetion is alasslfied by Stete law as oither private or <br /> confidentlal. Prlvate dala is informatlon whleh genEraffy cannot be given to the public but can be glven to the subject of the <br /> data. Confidentlal data is informatlon which genarally cannot be given to either the pwblic or the subJec! of the data. Our <br /> purpose and intended use of thls information is to annually updato our records and records oF other governmantal agencies <br /> re uired b law. ►f ou refuse to su I the lnformation the a 1lcation ma not be Issued, <br /> Applicant's Signafure; Date: <br /> Las[Updated: 03-01-7.011 <br />