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�u�� �� #/�1 q� �/��a�t <br /> b <br /> � C ity of O ro n <br /> Building Permit Application or lnternal Work <br /> (v�indows, daors, sidin , r -roof, etc.) <br /> M&iling Address: �„�n � � (.� <br /> Og,Q�,O PO Box 68 Permit number. �__y.�, <br /> Crys4al Bay, MN 5532�-OOBB Date received: <br /> � � Street Address; Received by: <br /> �, 2750 Kelley ParkWay Plan feview fee: <br /> �k�uo��'G Orono, MN 55356 <br /> �-� Total Fee: �'��.Q� <br /> Main: 952-249-4600 Fax: 952-249�616 www.ci. �ono mn,us <br /> This application form Tr+ust be completed in full and all req ired information must be submitted. <br /> Incomplete applicativns will be retur ed. (Please prinf) <br /> GENERAL IN�'ORMATION: <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers howcase H�me o�other Display Home? Yes No <br /> /f yes,a specia/event peim/t Is raquired with Police Depa�tmern and City Coun�il ap va160 days p�ol to the eVent. Shutf/e bus servic0 WIII b� <br /> required unless applicant demonstrafes sufficient on-site parking Is avai! b/e. Non-pertnitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR TION: I- � <br /> Name: 11 � ��(�5�� CT f �• <br /> State License# Expiration Date: �Q ' <br /> Phone: - �O - Q OffiCe cell <br /> Mailing Address� (p u Cit : L ZIP;�� <br /> Contact Person; Applica t is:X Contractor / Homeowner �c�roie ono> <br /> Emaif andJor Fax� � <br /> PROPERTY OWNER INFO MATr�N: M � <br /> Name: l �+�- 1 ) / ��9 n��C.GI I <br /> Phone(day): <br /> Address: s� Cit � n ZIP; 3 <br /> Email and/or Fsx <br /> PROJECT INFORMATION: <br /> Type of Project: Any eaRh movement may require <br /> MCWD review&permits <br /> ❑Door(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Wetershed District(MCWD) <br /> ❑Window(s) ❑ Repair l�Storm bamage 18202 Minnetonka Blvd <br /> / - Deephaven, MN 55381 <br /> ❑Siding ❑Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-�71-0682 <br /> Re-roof ❑ Fire Damage � www.minneh�h891�ek.ar� <br /> Overall ProJect Description� r � q,. -n <br /> Estimated Construction Valuation of Pr t excluding nd) 00 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by ihe BUildin Oepartment; <br /> • Certifies that the information supplied is true and corred to the best of his/he�know�edge. The applicant recognizes that they <br /> are solely responsible for suGmitting a complete application being a are that upon failure to do so, the staff has no alternative <br /> but to rejea it until it is compl�te; <br /> • Some or all of the information that you are asked to provide on thi application is classifled by State law as either private or <br /> confidential. Private data is anformation which generally cannot be given to the public.but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be iven to either the public or the subject of the data. Our <br /> purpose and intended uee of tfiis information'is to annually updat our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su I the information the a licati n ma not be issued. <br /> Applicant's Sig�ature: Date: ���y �Q�Q <br /> Last Updated: 05-04-2009 <br />