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c:ity oT uron � I� <br /> r Buildin Permit A lication f r (nternal Work <br /> 9 pp <br /> r (windows, doars, siding, r oof, etc.) <br /> �O� MBiIiP ��. Pemlit number '�a� �p�.� <br /> � � <br /> Crystal Bay,MN 55323-0066 Date received; I �a /� <br /> e, Sheei Add�ss: Received bY: <br /> ,� 2750 Kelley Parkway Plsn review tee: <br /> �.����G Orono.MN 55358 <br /> — Totsl Fee: l �Q, �� <br /> Main: 952-249-4604 Fax: 952-249-4816 www.a, rono.mn_us <br /> This application fvrm must be oompleted in fuU and all required iniormation must be s�ubmitted. <br /> incamplete appllcations will be retumed. (Please print) I j <br /> GENERAL INFORMATION:, <br /> Job Site Address: ,3��1 D.� � � �e �,�001�� /'Y� /1� <br /> Will this be a Parade of Homes, Remodelers Showcase Mome or other Display Home? Yes Na� <br /> ff yes, e speCJa!evern permit is req�iugd with Aorice Aepartment and C1tY Ccuncil approve180 days prbr to the svenG Shutde bus a�rvfae wiN ba <br /> requir6a wlAass appticant demonstrelas sulFiCfent on-aRe parking!s aver7ae►e. IVor,-parminea e►renrs will nor be allowed. <br /> CONTRACTOR 1 APPLICANT INFORAAA710N: <br /> Name: OryLe �.�-�' Li� � I <br /> StaDe License# O Expiration O�te: Q ' / .� v I <br /> Phone: G 2� - E S= office G ' ��--S 3 S (�II) I <br /> Mai�ing Address: /. "�c1�� . Ci : ' m�l�/✓ ZIP� �:5 3/G I <br /> Contact Person: ��; ✓' � R, r�GS t l� Applicant is: Coniractor 1 Homeowner �c����e on.� <br /> Email and/or Fax; vrr�� ,�X�/��e S'S� ,�����,�G�L�'�,/G �? �rn,9�/� Con� � <br /> PROP�Rn owNER INFORMAnON: � I <br /> Name: �/c� ✓I!a ��/S'V D �i7ii(O ifE} , ' <br /> � <br /> Phone(day): ���_O ) a� � `�6 f 6 ��; ��fl�0 , ZIP: I <br /> Address: 3 y DJ�-' _F• Gacu� <br /> Email andlor Fax --1— <br /> PROJECT INFORMATION: <br /> Type of Project: Any es�th movement may require i <br /> MCWD review 8►permits <br /> ❑Door(s) ❑Remodel ❑Water Oamage <br /> Minnehaha Cr�ek Wstershed District(MCWD) <br /> ❑Wirldow(s) 0 Repair ❑Storm Damage 182U2 Mln tonka BNd � <br /> ,�/ Deephave MN 55381 <br /> ■t Siding ❑ Reatof8tion ❑ Othor•(spedty) Phone' 8 -471-Ob90 <br /> Fex� 71-0682 <br /> ❑Re-roof L.7 Frs Damage www.minne <br /> ove�at�Proje�t DescriPt;en: . <br /> Estimaied Construction Valuatio� of Projeci(sxcluding land) ; . 5�3 <br /> APPLICANT ACKNQWI�EDGEMENT: . <br /> • Agrees to provide all 1Mortnatian required or requested by the Buildinp Departmen� <br /> • Certifies that the infarmalion supplieQ is true and corre�t to the best of hisJher knowledge. 'fhe a licant cecognizes that they <br /> are soley responsible for submitting a oomplete applicatio�being aware thet upon failure to do so the staff hae no attarnat{'ve <br /> but to reject it until it is oomplete; <br /> • Some or all of the informatlon that you are a6ked tfl provide on this appliC1ti0r1 is dassibed by S law as elther prnrate or <br /> c0A6deMial. Private dara is informetion which generaNy cannot be given to the public bu1 can b �iven to 1he�subj of the <br /> dats- Confldential data is irtformation which generalty pnnol be given to either the public or th subject of the d ta. Our <br /> purpase end intended use of ihis information is tn annualty updata our reoords and r�corvs of a er govemmental �genctes <br /> t uired b 18w. lf ou reluse to su I the irtfonneAo the a 'cabon ma nal be issued. . ' <br /> A licant's Si nature: �:/ ��— Date: � I� /�/��QJ <br /> PP 9 � <br /> ; <br /> last Updated: 05-04-200e <br /> T 'd �9TEEZEE9L eipeN e6S =60 60 bi � Q <br />