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NOVr'23/2C�?0/TUE 01 � 26 PM P. �02 <br /> j Cifiy af Orono . <br /> � Building PermNt Application for tnternal Work . . .. � <br /> ; � (wir�dows, doors, siding, re-roof, efc.) � � <br /> , . Mailing Address; Permit nUmber: '�U �� � <br /> .¢,Q�, PO Box.�6 . <br /> O � �Crystal Qay, MN 55323-0066 Date re�eived: ID <br /> ��'. � �. ' Received by: . <br /> � �,, Streef Addross: . <br /> ` ,r��• 2750 Kallcy Parkway Plan�revlew fe : <br /> �`t���s���'�,�� . Orono.MN 55356 • . , <br /> Total Fee: �i � �� 3 R <br /> Main: 952-249-4600 �ax; 952-249-4618 www.cl.orono.mn.us U <br /> This application form must be completed in full and all required Information musc be submitted. . .� � . . , <br /> . � Incomplete applications will be returned. (Plesse print) ' . . . <br /> G�N� AL INFORMATION: � � .�. � <br /> J.ob Si�e Address: � � � � ��0 V L� C�Q ,�,C. �/�/ �.L. . . � <br /> Will this be a Parade of Horr�es Remodel�rs Showcase Home or other D�splay Nome7 � Yes.. O�No . � <br /> r,. _ .. . .. : . . _ . � � . <br /> .. <br /> !f yes,a special evan(permlf is requ r��ollce�itment a�tli -CllyCimrreU�approval-8�-day��pYlo�ta-�ne-�ver�t�MaFUe-pu,s�servi�e-wil�b„ •• • <br /> fequllBd unless appliCenr tlemonstrateS SU117Clenf on�ite parlcing ia evallebla. Non-pormlusd'event8 wlll nof be P!lowpd- ' . : <br /> CONTRACTOR/APPLICANT INFCfRMAT10N: � • � , <br /> Name: � ' . . , ' OC�� Q� � !/� 0/)XS <br /> State �icense# � _Pe��a WiiZdovvs &T�ooXs , q' � y s - d �� � � � " . <br /> Phone: 15300 25t1�Ave N. Ste 100 . � (c�'0) <br /> Mailing ddress� ; �p�ya�outh,MI�55�4�4� • ZIP; � , ' <br /> Gont�ct erson: .lomeowner �ci�aa o�e� <br /> �m�i� a /or Fax� Lxc#201658841'11. 763/745�1400 , � � � � - � . . <br /> PR�P��TY OWN�R,iA�ORM 710N: ' . - : <br /> Naine: _ / �!l l' �4-L � S1M 5 0 � . , <br /> Phone (�ay): 1 y o • S L . <br /> Address: / v 4 S�L �!' ci : � zIP: <br /> Email and/or Fax ` � . � � �� <br /> PR0.IECT INFORMATION: qn �eartn'movemene ma re ulre <br /> Type of ProJect: y y 9 <br /> MCWD review S permlts . <br /> ❑ Doof(s) ❑Rmmodel � ❑Water Demago . . <br /> Minnehaha C�eek Watershed District(MCWD) <br /> Window(s) Repalr ❑Storm Damape . 18202 Mlnnetonka Blvd <br /> Desphaven, MN 55391 <br /> ❑ Slding ❑ Restoration ❑ Other:(specify) � �• �Phone: 952-471-0590� . .. <br /> Fax: 95Z-471-0662 - <br /> ❑ R8-foof ❑ Fire Damage wvwv.min ahacr ek.o <br /> Overall Pro'ect Description: L�) � 0�l.�f /'( �/-l''1e f � � �. k�� �.�1 <br /> �sYimated Construction Vsluation of Pro'ect eXcludin la d $ � ' " ' � ' �' � " � -,' <br /> � ( g ) � / 7',: �'. b �: <br /> App�ICANT ACKNOWLEDGEMENT: � • � <br /> � Agrees to provlde al!inforrnation requlred or requested by the Bulldf�g Department; . . � � � � � <br /> .. • C.1ertifies Ihat tha inforrnatlon supplled is true 2nd correct to the best of his�her knowledAe. The applicant recognizes ihat th6y <br /> are sorely responsibi�for aubrn�tting a complete aDPIICation�being awafe that upon failure to do So, the sts�F�hes no alternative <br /> b�ut to reject it until it IS COmplete; , � <br /> . Some or aJ( oi the information that you are asked to provlde on this appllcation is classlfied by State law as either private or <br /> cvnfidcntial. Private data Is informatlon whiah genewally cannOt b� given to the public but cen be given to the subject of the <br /> data. Contidential data is information whlch generally cannot be glven to either the public or the subject of the data. Our �� <br /> pNrpose and iniended use of this Information Is to annually update our records and records of other governmental agencles <br /> f6qulred b 18W. If ou refuse t0 su I the inforrnatlon,the a Iic�Slon ma not be issuea. , <br /> ' �- � �� �� � t� o . <br /> ApplicanY Signature: � Dst�: <br /> Lasc Update : 05•04-2009 � <br /> I ' <br /> � <br />