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r R <br /> City of arnno <br /> Buiiding Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailin Address: ' ' ' ,,' � <br /> g,�j� PO Box 66 Pemilt numbe'r:� ����� �.�J� <br /> � 0 Crystal Bay,MN 55323-0066 Date received;;;� � ` � ��i.°: <br /> a 5treet Address: Received by,.':.:�'.�;.: - � <br /> � � 275o Kelley Parkway Plan revlew fe�! . ' <br /> �"g�ax�$ Orono, MN 55356 ,. " : <br /> Total Fee�.:.��: *� �.��: .. <br /> Main: 952-249-4600 Pax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all requlred fnform <br /> ation must b�submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATIO � <br /> JOb Slte AddfeSS: .g4� �S c_-c� Cji n�'C� c�.� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home7 ❑Yes No <br /> If ycs,a special evant permit is required wrlh Police Department and City Council apprwal 60 days prior to U�e event. Shuftic 6us so�vlm lll e <br /> required unless applicant demons(rafes sufficienf on-site perking is Availeble. Non permitted events wil!not be allowed. <br /> CONTRACTOR/APPLI�ANT IN ORMATIO : <br /> Name: (��:n r�P � C O✓��'"C� G�(9•%S Z�r�G. <br /> State License# � Explratlon Date: � - ? / - 2.0 � 2 <br /> Phone: � office cell <br /> Mailing Address: � S I h � Ci : dv Z�p' 3 0 <br /> Contact Person: 7�� Applicant is: actor / Homeowner �a��ia o�a� <br /> Emai!andlor Fax: __��, ? 7/„7 .- �� � <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Add�ess: ��_Q c� c�.s c o A�,��-e��O�� c�hr; �rc��, o. z�P: �".�3 3 / <br /> Email and/o�Fax <br /> PR�JECT INFORMATION: <br /> Typ�of Projoct: My earth movement may requlre <br /> MCWD revlew&permlts <br /> ❑Door(s) ❑Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWO) <br /> ❑Wlndow(s) � Ftepair ❑Storm Damage 18202 Minnetonka BNd <br /> Deephaven,MN 55391 <br /> ❑Siding ❑ Rostoration ❑Dther.(specity) Phone: 952-471-0580 <br /> Fax: 952-471-0682 <br /> R�roof ❑ Fre Damage www.mirtnahahacreek.ora <br /> Overall Project Description: � Pd __ �-fou S� � �. <br /> Estimated Construction Valuation of Project(excluding land) $ � pp ' <br /> APPLICANT ACKNOWLEDGEMENT: <br /> ■ Agrees to provide all irr�orrnation required or requested by the Building Departmen� <br /> • Cerlifies that the information supplied is true and oarrect to the best of his/her knowledge. The epplicartt recognizes that they <br /> are solely responslble for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until 1t is complete; <br /> • Some or alI af the irdormation that you are asked to provide on thls appllcatlon Is classfied by State law as either p�ivate or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data_ Confide�tial dats is information whlch generally cannot bei glven to either the public or the subject of the data. Our <br /> purpose and intended use of this informatlon is to annually update our records and reoords of othor govemmontal agencies <br /> re uired b law. If u refuse to su I the informatlon,the a lication ma not be issued. <br /> ApplicanYs Signature: � 'v"-� Date: � v � ` �O <br /> Last Updated; 05-0a20D9 <br /> ie�i0•d zs:0i 0S0z-90—�flf <br />