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JUN/23/2015/TUE 01 : �5 AM Elder Jones Building FAX �10, 952 854 4909 P, 002 <br /> , <br /> City of Qrono <br /> Building Permit App[�cation �'or Inte�rnal Wor-k <br /> (windows, doors, s'rding, re-roof, efic.) <br /> -CL,�,� M�//�Pb Bo�r66 , Permit number: � <br /> i ~ <br /> //Dy- � Crystal Bay, MN 55323-0066 Date received: � <br /> r�'- <br /> 1.;;,��,� Receive� bY- <br /> I� �`� :" ,� Streef Address: � rn�� <br /> � '�,���:;-- <br /> ,�, ;�}����� G� 2750 Kellay Parkway Plan revie�vfA9' <br /> ��'�� � Orono, MN 55356 � <br /> ��ES�I� <br /> Total Fee: � Z,g' , Z� <br /> Main: 952-249-4600 Fax: 952�249-4616 www.cl.orono.mn_�s <br /> This application form must be completed in full and all required informatian rriust be submitted. <br /> fncorrtpl�te app(ications will be returned. (Please prinf) <br /> GEN�RAL [NFORMATION: <br /> Job Site Address: ��� � Q �j C 0 �4 /l�.� �� <br /> Will this be a Parade of Hames, Remodelers Showcase Home or otf�er!]ispiay Home? Yes ' No <br /> ff yes,a special event permlt is r�equired with Po/ice Dapartment and Clry Counc!!approval o�days prior to tha evenl. Shuttle bus scn�ica wrl/be <br /> requi�ed unless applicAnt demon.sfrates su(ficiant cMsite pa�king Is available, Non-permitfed ev�nts wlll nof be allowed, <br /> CONTRACTOR!/aPPL.1GANT i1V�Ot2MATION: q 5� �y S� G e y 7 <br /> Na�ne: � <br /> state ucense# �el�a Noz-�hland <br /> Plicn�: 15300 25th A�ve N_ Ste 1 p0 cell <br /> Mailing Address: Plymouth, MN SS447 ��p= <br /> contact Person; - - Lic#BC645090 Ph. 763/745�140Q �omeowner (C�rcle One� <br /> Email and/or Fax: <br /> Nam�e:���OWNE��OR;ATIqo:� n C � K <br /> � <br /> Phona(day): � C . / � 1 <br /> Acdress: �� �( 6 L�SI o _0 a Q Gi ;W GZ' Q. j-� ZIP: J�� <br /> �mail and/or Fax <br /> PR�J�C7INFORMATION: - <br /> i Type of Project: � Any earth mOv�mant may require <br /> MGWD revieW&peXmits <br /> ❑ Ooor(s) ❑ Ramo�ei ❑W8t6r Damage <br /> Minnehaha Crezk Watershed Distr'iCi(MCWD) <br /> `�Window(s) ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> , ❑Si�ing � ❑ Restoration ❑ bther:{specify) � Phane� 952-471-0590 <br /> Fax; 952-�!'�1-0682 <br /> ❑ Re-roof �] Fire Damage w�nnN.minnehahacr22k.Q� <br /> Overall Project Description: '� �� � <br /> Estim�ted Construction Valuation vf Aroject(exclu ng ]and) $ 'rj' <br /> APPLIGANT ACKNOWLEDG�M�NT: <br /> . Aorees to provide alf information requir'ed or rAquested by fhe Building DepafimenY; <br /> � CeRifes that the information supplizd is truE and correcf to the best of hislher knowledge. The applicant feCOgnizes that they <br /> are solsly responsible for submitfing a Complete application being aware that Upon faiiur�to do so, the staff has no alternative <br /> but to rejeGt rt until It is compleEa; <br /> • Sorrte or all of t1�a information that yau are asked to provids on this app[ication is classified by State law as ei�her private o�- <br /> confidential. I'rivate data is information which generally Cannot be yiven fo the public buf Can be given to the subjs�t of tne <br /> data. Gonfidential data is informatiorl whiclz gen�rally cannot tre given fo either the public or the subjeCt of th0 data. Our ' <br /> purpose and intertded use of this information is to an�ually update our recbrds and records of other govemmental agencies <br /> � required by law. If you refuse Yo supply tlie information,the application may not be issued` _� <br /> Applicant's Signature_ � Date- � �l a �` � <br /> � <br /> _ast Updatetl: U5-04-2009 <br />