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city ot Urono <br /> Building Permit Application fo�- Internal Work <br /> . (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: pemtit number: �� "�� a� <br /> ���,�.� , PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: U� <br /> ;/'� r�- --` Q <br /> I�� �� y �,r! Streei Address: Received by_ <br /> �'�, . � �`�� v�� 2750 Kelley Parkway Plan review fee: <br /> '�/� Orono, MN 55356 <br /> t9x���"/ Total Fee: � � <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 printj <br /> GENERAL INFORMATION: <br /> Job Site Address: � �pc'� — � �/ �.� <br /> Will th�is be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes, a special evenf permit is required with Police Department arrd Ciry Council approval 60 days pnor to the event. Shuttle bus service wdl be <br /> required e�nless applicant demonstrafes suffibient on-site parking is available. Non-permitfed events will not be a!lowed. <br /> CONTRACTOR/�PLICANT INFORMATION: <br /> Name: � '� ' � � �� ;,,� <br /> State License# Expiratio Date: ''���p <br /> Phone; ,� �I -'1 ;� o�ce � - 'S{S -�� b cell <br /> Mailing Address: "1 ^� � C, Ci : � ZIP: S'�^ �, <br /> Contact Person: � �- Applicant is: raet r �/ Ho owner �c����one� <br /> Email andlor Fax: , (- 6�S- 1'3� �o+� <br /> PROPERTY OWNER I�IFORMATI <br /> Name: �� �,�� <br /> Phone (day}: � - "�?��i- '1 ZIP: ��'�� � <br /> Address: �'�pp ��„��P� ��,�_ City� Q�s�p <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movecnent may r+eqaire <br /> MCWD review 8�permits <br /> ❑ Door(s) ❑ Remodel �lUater 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�71-0590 <br /> �ax: 952-�71-0682 <br /> ❑Re-roof ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Yaluation of Project(excluding land) $ l,�'G� •C76 <br /> APPLICANT ACKNOWLEDGEIUIENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • CeRifies that the information supplied is true and correct to the best of hislher know�edge. The applicant recognizes that they <br /> are sofely 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 applicaiion is classified by State law as either private or <br /> confidential. Pnvate data is informativn which generally cannot be given to !he public but can be given to the subject of the <br /> data. Confidential data is information which generaEly cannot be given to either tfi�e publ3c or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governrnental agencies <br /> re uired b law. If ou refuse to su 1 the information,the a lication ma not be issued. <br /> �, . <br /> ApplicanYs Signature: �� Q�,�-�,�� Date: �'-I b-G� <br /> Last Updaled: 05-04-2009 � <br /> C��k- `4-t� f5��-�' f�'/ifi�v.�J� � C-�N�-� //`'f�J' <br /> / � <br /> �,� /��� /�,t;�/r��w (��-'� � <br /> � �� � <br /> l'd b088E6t��9L diysue�{uel8 Pl�uoa dE9�60 60 9� ��f <br />