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Sep 30, 1_1 11:21a Schenkel 9524701781 p,1 C ity of O or�o Buiidir�g Perrnit Applicati n for Ir�ternallNork (windows, doors, sidi g, re-roof, etc.) Mailing Address: permit number. O70 /—f> / O.¢,�,�,0 PO Box 66 Crystal Bay,MN 55323-006 Date received: 9 �,� Street Add�ess: Receivecf by: �,� �titi 2750 Kelley Parkway Plan reviewfse: �q�E�o$�v Drono, MN 55356 Tafal Fee: ��. �� Main: 952-249-46fl0 Fax: 952-249�fi'�6 www.ci. rono.mn.us This applica�ion form must be completed in full and al required information must be submitted. Incamplete appEications wfll be tu ed. (Ptease prin� GEI�ERA�INFORMATIOhf: �� d�� Job Site Address: � Will this be a Parade of Hotnes, Rernodeters 5howcase Home r other Display Home� Yes Ho !f yes,a specia�event psrmit is�equired with Police Deparfment and City Coun /appmval 60 days prior to the evenL Shuftla bus senri�e wr71 be ra�uired unless applicant demorrsb afes sr�rcienf on-site parking is vailable. Non-pennitted events wFff not be eflowed. CONTRACTOR�APPLICANT lNFORMATION: Name: �i-�.c.l� �2 �,n�.o..r- r'�,S�.S �' C State License# �.�,� Exp�ration Date: J3 Lead Certification Number: N,4-f �J �yG�—� � Expira:ian Date: �� (for work an homes that were constructed prio�to 1978 Phone: �� `�7� cU E� (office) (cell) Mailing Address: �,� _ ,y� )� o�-o[ City: S S��l�k ZIP: ,T,��/s"�3/ Contact Person: ��,) Appl nt is: Co tractor / Homeowner �c�R�e o�e� Email and/or Fax: � _ 7 — l 7 '/ . PROPERTY OWNER INFORMATION�- t (�`� i�ame: �-��Q- �l`� Phone(day): � Address: City: ZIP: Email andlor Fax � PROJECT INFORMATION: ' Type af Pruject: Any ea�th movement may requi�e MCWD review 8 permits: , ❑Door(s) ❑ Remodel ❑Water Damage Minnehaha Creek Watershed Dis�rict(MCWD) ❑Wis�daw(s) � Repair ❑ Storm Damage 18202 Minnetonka Blvd Deepha�en,MN 55381 ❑Siding ❑ Restoratian � Other: (specify) Phone: 952�7'I-0590 '�Re-roof ❑ Fire Damage Fax: 9�2-479-0682 www.m i n n e h a fn a cree k.o r4 Overall Project Descriptinn: Est�mated Co�structian Valuation of Project(excluding Eand) $ Cj 'd - APPUCANT ACKNOWLEDGEMENT: • Agrees t�provide all infarrnation required ur requested by the Buildin Depar3rnent; � .� - • Gertifies that the inforrnatio� supplied is t�ue and correct to the best of his/her knowledge. The applicant reoognizes that they are solely respo�sible for subm�tting a complete application being a are that upon failure to do so, the staff has no alternative but to reject i�until it is complete; • Some or aH of the informa6on that you are asked to provide on thi appfica��n is classifie� by State faw as either prNaie or confider�tial. Private data is infiormation which generally cannot be iven to the public but can be given to the subject of the daFa. Confiden�ial data is inf�crnation which generally cannot be g en to either the p�blic or the subjecE of the cfata. Our purpose and intended use of this inf ation is o annually pdate ur reoords and records of other govemmental agertcies re uired b law. if ou refuse to s� the info ation,the a licatio a not be issued. ApplicanYs Signature: �� 3 � �,r Date: l.ast Llodated: 03-01-2011