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City of Or no • Building Permit Applicatio for Internal Work (windows, doors, sidin , re-roof, etc.) Mailing Address: Permit number: g,�,j� PO Box 66 �J O Crystal Bay, MN 55323-0066 Date received: `��,�� ,� �``�`-�; �, Street Address: Received by: �',�, ' 'F'��~ �ti 2750 Kelley Parkway Plan review fee: t`�kEsxo4`'� 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 r urned. (Please print) GENERAL INFORMATION: Job Site Address: 3�� S� �� Will this be a Parade of Homes, Remodel rs Showcase Home o other Display Home? ❑ Yes ❑ No If yes,a special event permit rs required with Police Department and City Counc approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is vailable. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: �,1 c l;r�-- ��-1' F,�' �.r�c= State License# ,�� ; " ; , 3 j Expiration Date: /"� Lead Certification Number: Expiration Date: (for work on homes that were consfrucfed prior fo 1978 Phone: 5'_>"� - y �1_ ��; ��- (office) (cell) Mailing Address: ,� � � r3,�� ,,� p� City: �, r;�,z_�,,%`� _ZIP: , ��--� �j Contact Person: C3�Y� S�_�� App icant is: ntracto / Homeowner (CircleOne) Email and/or Fax: ,;� - 7 ^, _ �� l PROPERTY OWNER INFORMATION: Name: .T� �,ti� C, -sC;�� Phone (day): ()� - �/ �, _ y y/� Address: City: ZI P: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Siding ❑ Restoration ❑ Other: (specify) Deephaven, MN 55391 Phone: 952-471-0590 �Re-roof ❑ Fire Damage Fax: 952-471-0682 www.minnehahacreek.orq Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ ,S� C, r— APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Buil ing Department; • Certifies that the information supplied is true and correct to the b st of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware 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 on is application is classified by State law as either private or confidential. Private data is informati which gen Ily cannot e given to the public but can be given to the subject of the data. Confidential data is informatio which gene ly cannot b given to either the public or the subject of the data. Our purpose and intended use f this in rmation is t nnually up e our records and records of other governmental agencies re uired b law. If ou refu to su I the inform on, the a c tiom m �ot be issued. ApplicanYs Signature: Date: G -��-�—;�� Last Updated: 03-01-2011