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City of O ono <br /> . Building Permit Applicati n for Internal Work <br /> (windows, doors, sidi g, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> O�v D,�O PO Box 66 <br /> �� <br /> Crystal Bay, MN 55323-006 Date received: <br /> �'� Received b <br /> � �� �`�'�` a, Street Address: Y� <br /> x'� ' '3�„ �ti� 2750 Kelley Parkway Plan review fee: <br /> L�ESHO�`'� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci. rono.mn.us <br /> This application form must be completed in full and al required information must be submitted. <br /> Incomplete applications will be r urned. (Please print) <br /> GENERAL INFORMATION: ,_., `� <br /> Job Site Address: G ��' S (�cL - �� � (c.�.,h l/l�7/l S "3 <br /> Will this be a Parade of Homes, Remodelers howcase Home o other isplay Home? ❑ Yes No <br /> If yes, a specia/event permit is required with Police Department and City Counci approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is ailable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: .,� u,.� -� Q-,�5 C�„ ,��j �TJ;L-�S <br /> State License# �(� � Expiration Date: -3�- � <br /> Lead Certification Number: �-� - c-/ � � - �l - �O� ��/ Expiration Date: <br /> (for work on homes that were construcfed prior to 1978 <br /> Phone: -7L j- (�_`�,,�, c� C� (office) (cell) <br /> Mailing Address: � /{w. �,`; City: �c � ZIP: "-� � <br /> Contact Person: ��q.�,� Appli ant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax. , (L�, _ - � � <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��� �;n �,� <br /> Phone (day): �� � - � �� <br /> Address: /d � ; � City: ✓l � y���,/� ZIP: ,�) ' � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 <br /> ��e-roof P hone: 952-471-0590 <br /> ❑ Fire Damage Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Overall Project Description: f � S��� � � ��- <br /> Estimated Construction Valuation of Project(excluding land) � ' C�U <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 f his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aw re 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 pplication is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be g ven to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be gi n to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update o r records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information,the a fication ma not be issued. <br /> ApplicanYs Signature: �I'(� � �/`� Date: �' ���—�) <br /> Last Updated: 03-01-2011 <br /> � <br />