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�. til�� � � , r� <br /> � City •f •r�n• �v� �al� <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: a�d�0"4l�lv� <br /> Og,�,�.0 PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: �l"�—�� <br /> ,� �' ��?,; ,, Street Address: Received by: <br /> �'�n ' '�� ���' 2750 Kelley Parkway Plan review fee: �3• � <br /> r9kESH0¢� Orono, MN 55356 0��5 q <br /> Total Fee: <br /> ��� / <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: y�/� <br /> Job Site Address: �'ej�(� � ���� ,���� (,���' ���L; /�' � ��J��'� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [�filo <br /> If yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP,LICANT INFOp�ATION: �` <br /> Name: �i,�tC c� (s'j C�yt cGf l� <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: Cit : ZIP: <br /> Contact Person: Applicant is: Contractor / Ho eow er- Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMA ION: t <br /> Name: �.e�'1'1C_E' ��G��� {� <br /> Phone (day): , � � . �a ,� <br /> Address: 2'7siCy �--�-/�� /,�_ City: L.�f«'r1,2� ZIP: �J�:��'j' ) <br /> Email and/or Fax L��.1�r�=�o �. t�oc,�i�3te�,WT2c"r��:c �G-�'n'� r <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review 8�permits <br /> �Door(s) �Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orQ <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ ��, � s� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information 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 given to either the public or the subject of the data. Our <br /> purpose and intended use of th�n.far.mation is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou re o su I the`infi�rmation,the a lication ma not be issued. <br /> ApplicanYs Signature:- Date: �� � �� <br /> r <br /> Last Updated: 05-04-2009 <br />