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SEP/10/201.5/THU 1G: 02 P� Elder Jones Building FA� No, 952 854 4909 P, 002 <br /> � <br /> C�ty o� Orano <br /> Building P�rmit Appl�catian for Ir�tern�l Work <br /> (windows, doors, siding, re-roof, etc.) <br /> - MailingAddress: pormit numbsr� � f� I � <br /> ,-�,0��� PO Box 66 q 1 <br /> % �4� � Crystaf Bay, MN 55329-0066 Date rsceived: L 6 r� <br /> %� ., � � � <br /> � ;-;,.:��,•>. Received by: -- <br /> a�„� y`,�76:�.,;R.� �,� SfreetAddress: �--- <br /> '� 1��";��;H s, <br /> �� t.h 4 2750 f<elley Parkway Plan review fee: <br /> �\�,�����i��`�,�� Orono, MN 5535s <br /> ���tEs�o�.• �� . <br /> ��,��� Total �ee: <br /> M2if1: 952-249-4600 Fax: 952-249-4fi16 v�nniw.ci.orono.�':n.us <br /> �� This ap�lication form must be completed in full and a!1 required information must be subrrtitted_ <br /> Incomplete applicatians wifl be returned. (Please prtnt) <br /> GENERA� INFORMA710N� �Y � C � <br /> Job Site Address: <br /> Wiil this be a Parade of Homes, Remodelers Stlowcase Home or ather Display Home? ❑ Yes ❑ No <br /> �f yes,a spvcia/event permit is raqurred with Pvlice Depar7ment and City Gouncil approva/60 days prior to the event. Shutt/e bus�ervlCB Will be <br /> rEpuired unlass&pp(ica�7t damonstrates sufficient on-s)te park�ng is avallab/e. Non-p�rm/i[ed events will not be a1lowed. <br /> CQNTRAGT�R 1 APPLICANT INFORMFITION� <br /> Name: �S�f�N$ • 4 b�7 _ <br /> 5tate L.icense# Pel1a N�oxtl�.land � o . , <br /> Phone: X,5300 25th AveN". Ste �00 (cel[L <br /> Mai(ing Address� _ W� Pl�mlouth,MN 5�447 ZIP: „ <br /> Contact Person: Lic#$C64$090 Ph. 763/745-1400 lomeowner (Circle One) <br /> Email and/or Fax: -- <br /> PROP�I2TY OWN� NFORNfA7! N: <br /> Nam.e: U � a <br /> Pl�on�(day)= S7 z� • l J � . Q I'"� r1 � z�P� S�3 `I1 <br /> Address: �� ,� o � G� - <br /> Email and/or Fax <br /> PR�J�C7 INFORMATION: <br /> Type of Projecf: � Any earTh movemerlL may require <br /> , . MCWP Yeview& pertnits <br /> ❑ Coor(S) I ❑ Rampdel ❑`N�ter Damage � `^� <br /> � Minnehaha Creek Watershed District(iv1CWD) <br /> `�Window(s) i�epair � ❑Storm Damage , "I H2O2 Minnetonka Blvd <br /> � Deephaven, MN 55391 <br /> ❑Siciing ❑ Restoration 'i ❑ Other.(speeify) � Phone: 952-471-OS90 <br /> Fax: 952-471-0682 <br /> I �� RE�roof � ❑ Fire QarYtaga ^ ww�n�.minneYtiaha r ek.or ' <br /> pveraEl Project Description: / � trb L b� �n� <br /> JEstimated Canstruction Valuation of Project (exc uding"Eancl) $ <br /> APPL(CANT ACKNOWL��GEMENT: <br /> • Aarees to provide all information required Or r6quested by fhe Eui[ding D9p2Ctmcnt; j <br /> . Certifies thaf the informafion supplied is true and correct to the best of his/her knowledge, Thg applicant reCognizes Ihat they � <br /> are solely responsibl9 for submitfing a complete application being aware thaf upon failure tU do so, the staff has no altemative <br /> but to reject it until it is Complete; <br /> ! . Sorrte or all of the ir,formation that you are asked to provide on thls applicatior, iS classified by State law as Pither private Or <br /> i� confidentiai. Private da;a is information which q�nerally Cannot be �iven to tlze pubEiC bUt can be given to the subject of the <br /> � data_ Gonfideniial daia is information which gen2rally cannot be given to eith2r the public 0� the subject of th� data. �Ur <br /> i purpose and inienctsd use of this informafion iS t0 ani�ually upd2te our recordS 8nd records of other governmen;al agencieS <br /> � required by I�w, ff you refuse to supplV the inforrnation the a IiCatiOn ma nof be�Ssued. <br /> Applicant's Signature� '" V � ___ pat�= � L � D L 1 s <br /> � <br /> Lasi Upda?eU QS-04-2009 <br />