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m:Auben Residential To:Royal PermitApplication (19522494616) 14:46 08/02/11GMT-05 Pg 03-03 <br /> � <br /> • City of Qrcrno� �� �ii <br /> . `� <br /> Building Permit �4pplication far Internal Vllork � <br /> (windows, door�, �iding, re-roof, etc.) <br /> �;-�� ~•�-`� Maifing Address,- OI � O7� <br /> %O� �O\l Permit number: <br /> 0 PO Box 66 <br /> Crystai Bay, MN 55323-0066 Date recaived; ��1� <br /> 3:�a �i�� ���� �, i' StreetAddress: Received by: � <br /> '��"� '� ��'�� �,�j J 2750 Kelley Parkway Plan review fee: _—__� <br /> '� Orono, MN 55356 <br /> \��.�t�uoQ'``'// <br /> :,,,-_---.:;.= ' <br /> Totai Fee: p��3,� <br /> Main: 952-2d$-4600 Fax: 952-249-4616 vrt,�����_c,;i,u.;c��r�,;,nn,:��:� <br /> This application farm must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please prinfJ <br /> GEIVERAL INFORMATION: -� , �� �L�'��-E�-� <br /> Jab SiEe Address: �- - <br /> Will this be a t�arade of Homes, Remadelers Showcase Home or other Q"rsplay Home? Yes No <br /> !f yes,a special event permit is required with Police Departmant and Cify Council approva160 days prior to the event. ShuRle 6Ls service will be <br /> requirod unless applicant demonstrates su�cient on-site parking is available. Non-permifted evenfs will nof tre 9(lowed. <br /> CONTRACTOR/APPLIC�NT IfVFORMATION: <br /> Name: �.�je(1 �j'SI�L'(1`��� _`... <br /> State License# �3 ' � Expiration Date: � 3 �Q�� <br /> Lead Certification Number: �-�- �g,;Zq Expiration Dat�: �� <br /> (for work on homes that were constructed�rior to 1978 <br /> Phone: ��- 7-��(P .�___._ _,__.(dffice) �f,�j"a�` 7/ '�'�J� (cell) <br /> Mailing Address: a � �l CitY: r1 �� ZIP' �3 <br /> Contact Person: J����iY7 p App(icant is: Cantractor I Homeawner �ci►�ie one� � <br /> Email and/or Fax: .r'.1��_ y-J.�p -,�j�� <br /> PROPERTY OWNER tNFORMAi'ION: <br /> Name: .�'ClC L�,l <br /> Phone(daY): <�};�- �/"7';�-�5�� <br /> Address: ��'�y�� ���;� �E�� _ City: �'j((`j�� ZIP: �j ���}( <br /> Emai!and/or Fax �E-v��j C'� �r�-{ v'v1,;tC�S, 'w�'1� <br /> PROJECT INFORMATI4N: <br /> Type of Project: Any earth mavement may require <br /> ❑Door(s) ❑ Remodel ❑Water Damage MCWD review 8�permits: <br /> ,�/ Minnehaha Creek Watershed District(MCWD) <br /> ❑Window(s) ❑ Repair L�'Storm Damage 1B202 Minnetonka Blvd <br /> ❑ Siding ❑ Restoration ❑dther: (specify) d�ephaven,MIV 55391 <br /> Phone: 952-471-0590 <br /> [�e-roof ❑ Fire Damage Fax: 952•471-0682 <br /> +_r•r;;�w r'r�:r,rtP't_lahacrc��i.�r� <br /> Overall ProjeCt Description: C� �C7C'� - — '��( J ,y� �;{ � <br /> Estimated Construction Valuation of Project(excluding land) $ � �; �';�� _ <br /> APPLICAIVT ACKNOWLED�EMENT: <br /> . Agrees to provide all information r�quired or requested by the Building Depa�tment; <br /> • Certifies that the infnrmation supplied is true and correct to thz best af his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware fhat upon failure to do so, the staff has na alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to pravide on this applicatian is classified by State law �&either private or <br /> confidential. Private data is information which generelly cannot be given to the public but can be given to fhe subject of the <br /> data. Confidential data is information which generafly cannot be given to eifher the public 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 governmental agencies <br /> re uired b law. If you refuse to supply the information, the application may not be issued. <br /> M1.+..li..-...F'w Cin..n4ii�..• � ,/ fl�.in� ,�y �^ �� I <br /> v � �, V ��r\��,f�t�'+^'.�, ! l l/�� � � <br /> �I���� <br />