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�'_� �'C'!F/Tv1C�":�i 10; 05 PP�'I Elder Jones Bui lding ��`.n: Tdo, 95� 854 4909 P. �10�' <br /> � <br /> . City of arono <br /> Building Permit Appfication �or Int�rnal Work <br /> (windows, doors, siding, re-roofy etc.) <br /> �_��� Maifin y Addrass; <br /> �j�L,�.�\\ PO Box 66 Pe'rmit number: ��S-D��(O <br /> �,Q , a�\1 Crystal eay, MN 55323-0066 Date reCeived: -J- l —I <br /> �a� ''�>`��'��•r I� Sfreet Address: RBCeived by: <br /> °�, ;:�;��">�'��'�'� �� 2750 Kelley F�arkway <br /> ,� ,•,,;-0.�� � o Plan review fee: <br /> o �(�+� <br /> �`���s�Yo�'� Orono, MN 55356 � <br /> -f Totai Fe�: I � / _• a� <br /> Main: 952-249-4600 Fax: 952-249-4616 vvww.ci.oronomn.�� �P <br /> This application form must be com�,leted in fulf and al) required information must be submitted_ <br /> Incomplete app(ications will be returned. (Pleasa print) <br /> G�NERAL. INFORMATION: . � <br /> Job Site Address: �� �{ � Q V( �° (,�j l <br /> Will fhis be a Parade of Homes, Reraodelers Showcase Home or other Display Home? Y�s ❑ No <br /> !f yes,a�pecla!�vant permit is reguired with Pollce Department and City Council approv&160 da��s piior P�fha evenf. Shuttle bus servlce wlll t�e <br /> �aquired unless applicant demonstrat�s suff;crant onsite park;ng is available. Non-permltled events wii�not be allowed. <br /> GONTRACTQR(APPLICANT INFORMATIQN: <br /> Name: �'S� �3y'�'j •� p q 7 <br /> State Lice�ise� �" 1'�-TD At-T�ome Service, �a�c, <br /> P)ione: , 2690 Cumbexland Pl�t��y, Ste 300 (Cz��) <br /> Mailing Address: A,tlant� CxA 30339-3913 Z�p� <br /> Contact Person: _,. Lic#, CR268257 Ph. 763/542-$826 lomeowner (Circic One) <br /> Email and/or Fax� <br /> PROPERTY OWNER I FORMATION: <br /> Name� �_ f <br /> Phone (day): � � � , � 5 � .�. <br /> Address: � � 7 4f �' 1�� Ly Ci T �1 Ci�/ Y G �6 ZIP: � S 3�'� <br /> Email and/or Fax "" <br /> PROJECT INFORMATIQN: � <br /> Type of Project: Any earth movement may reyuire <br /> MGWD review&permits <br /> ❑ Ooor(s) ❑ Remodel ❑Water Damage <br /> Minnehaha Creek Waterslied DistriCt(MCWD) <br /> ❑Window(S) �Repair ❑Storm Damaye 18202 Mini�r-,tonka Blvd <br /> Deephaven, MN 55391 <br /> ❑Siding , ❑ Restoration ❑Other,(specify) 4 Phone: 952-473-0590 <br /> Fax: 952-471-0682 <br /> �ropf ❑ Ffre Damaye � �Nvwv.minnohahaCre2k•orq <br /> erall Projecf Description: �.f e r �' /�u�� _��P� �� �� �o �_ I as c �� � �v �1�� <br /> Estimated Construction Valuation of Project (excludfng land) 7 � � <br /> APPLICAN7 ACKNOWLEDGEMENT: <br /> . Ayrees to provide a!I information required or requested 'oy the Building Department; <br /> • Cerfifies that the information Supplied is true and correc(to the be5t of his/her knowledge. The �ppficant recognizes that they <br /> • are solely responsibEe for Submitting a completa�ppflCatlon heing aware that upon failurg t0 do so, the staff nas no alternativ� <br /> but to r�jEct it Until it is complete; <br /> • S01ne or all of the io�fOrmation th8t you are ask�d t0 pfOvide orl this applicati�n is classified by State law as eitizer private oP <br /> confidontial. P�ivate data is informaiion whiCh generally cannot be given to the public but can be given to the subject of the <br /> data. Cor,fidential data fs informafion which generally c�nnot be given to s�ther the pubiic or the subject of the data. Qur <br /> purpose and intended use of this irtformation Is fo anr.ually update our recol'ds dnd records of othgr governmental agencies <br /> required b law. 1{ ou refuse to supply the information,the application may not be issued. �� <br /> Applicant's Signature: � ���� bate� �` 1 ( ( S <br /> � . _— _ <br /> Last updated: 05-04-2009 <br />