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' City of Or no � Building Permit Applicati n for Internal Work (windows, doors, sidin , re-roof, etc.) Mailing Address: Permit number: O�,�,�0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: � �� , � ��;!a �. Street Address: Received by: �'�,n '� a" �,� 2750 Kelley Parkway Plan review fee: L�kESHOg'� Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.o ono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be re urned. (Please print) GENERAL INFORMATION: . ,< -,. Job Site Address: % �;' y, �� .�� - Will this be a Parade of Homes, Remodelers owcase Hom or other Display Home? ❑ Yes ❑ No !f yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is a ailable. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: ��clti � v�.r� �^,�� State License# �c ' �' 3 Expiration Date: �% Phone: s, - 1- � office cell Mailing Address: , �; s� �� Cit : � �;�� ) ZIP: ��-3_3 • Contact Person: ;1( Appli ant is. ConCractor, / Homeowner (Circle One) �.`_,_ --% Email and/or Fax: '-- PROPERTY OWNER INFORMATION: Name: C�,1.�, � h� . Phone (day): � , � _ Address: Cit : ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require MCWD review&permits ❑ Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 Re-roof ❑ Fire Damage www.minnehahacreek.orq Overall Project Description: -�:�,� U� � �l ~r�--- �� . � �c�.�,�..— Estimated Construction Valuation of Project(excluding land) $ l � C,�j APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Buildin Department; • Certifies that the information supplied is true and correct to the bes of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being a are that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide dn thi application is classified by State law as either private or confidential. Private data is information which generally cannqt be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be iven to either the public or the subject of the data. Our purpose and intended use of�his infarmation,�S to annually update our records and records of other governmental agencies re uired b law. If ou refuse t su f ;the inf rmation,th a licati n ma not be issued. t Applicant's Signature: ' �� — Date: �r� —�'l� LastUpdated: 05-04-2009