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� r , � <br /> � <br /> Cit nf C�ra�no � � � 9 �/ <br /> Y <br /> Buitding Permit Appiication for In#ernal Work <br /> {windvws, doars, siding, re-roaf, etc.} <br /> �--�-:.-. Mailin Addrasx _ _ � CE <br /> ��,�,j�� PD Box 66 Permit number. �O�/ -�i'G�✓ <br /> +�O Q� Crystal Bay,MN 55323-0066 Dete reoeived: {�-/�-/ <br /> i`a_ ',a � Street Address: Received by: <br /> �\ ��' 275d KeNey Parkway P1an reyiew#e • <br /> �t� .$.� ��,�N�� �� � �3� ol <br /> __�, <br /> =__= Total Fee: <br /> Main: 952-249-4�00 Fax: 952-249-d81S www.ci_orana.mn.us � <br /> This appiic.ation form must be compieted in full and ali r�uired information must be strbmitted. <br /> incomplete applicafions will be reiumed, (Ptease prinf) <br /> GENERAL[NF4RMATIQN: <br /> Job Site Address: S p (�t'�►`�' �0 <br /> Will this be a Parade of Homes,Remadelers S owcase Hom r other Display H e? es No <br /> �f yes,a speciet euent pemv7 is required wttfr Polices Departmant end City Caunu!approvat 60 days prior to fhe euerrt. ShutHe bus servrce an71 be <br /> requtred unless appticant demonstrstes suft"ieiant on-site parkrngls avaits�bte. Non-perrrdtted evants wr7t rwi be aHowed. <br /> CONTRACTOR/APPUCAFIT INFORMATIQN: <br /> Name_ �'loPc�Or��i�.�rrieS �S�'fY.�c�tpV'\ <br /> State License� Expiration Date: �_ �_ E ^Z,,, <br /> Lead Certification Number: �„� �}- Expiration Date: <br /> (for wark on homes tfiai were caastn�cted prfo►to'19T8 � <br /> Phone: (?3- (otfice) f'Z. Su�'$'�'-- �,t� (cell} <br /> Mailing Address: , , Q � City ,� �4t,,� ZlP: �{'�� <br /> _ ___ <br /> Contact Person: � A�licant is: o tra Horneowner (Ckcb Ona} <br /> Emai!and/or Fax: � y�_ <br /> PROPERTY OWNER INFpRMATipht: `,. <br /> Name: 7 �''�_4�..� �t't��ev�.��.,�r�.f..�-- <br /> Phone(dayj: R�7. �ts� �, .�i�S'�g �} <br /> Address: �-� w. 3�,-i-�- S-t; City.�j--�t�S �"11C�zIP: �C,'� t{�,�, <br /> Emaa andtor Fax (�t�,t�tovti �c�.v'1�YK+E,1" f t'ovt�}t'tx,Wi.t�Yt.el'f� �,k,�� G! b•C�t7rv. <br /> PROJECT INFORMATiON: <br /> Type of Project; Any earth movement may roquire <br /> ❑Dnor(s) [j Remodel ❑Water Damage ���p��ew&permits: <br /> Minnehaha Creek Waiershed District(MCWD) <br /> ❑Wlndow(s} ❑Repair ❑Storm Damage 182fl2 Minnetunka Bivd <br /> ❑Siding ❑Restoratian ❑Other:(speclfy) Deephaven,MN 553$1 <br /> Phorte' 952-471-0590 <br /> ❑Re-raof 0 Fire Damage Fax: 952-471-0682 <br /> www.minneh ah acreek_orq <br /> Overalt Prajecf Description: „i <br /> Estimated Canstruction Valuation of Project(excluding land) � �.��,��,Q, <br /> APPLICANT ACKNC?WL�OGEMENT: <br /> Agrees to provide all informatian required or requested by the Building Departmen� <br /> � Certifies that the information suppiied is true and correci to ihe best d his(her knowiedge. The applicant�ecognizes that they � <br /> are soieiy responsibie for submFtting a complete application befng aware mat upon tailure to do so,the staff has no aiternative } <br /> but to reJect it until it is complake; I <br /> � Some ar all of the Informatian that you are asked ta provide on this appiicatia� is ciassified by Stale law as either private ar <br /> confidential. Private data is information which gsnerally ca�not be given to the puhlic but can be given to the subjecf of#he <br /> data. Confldenlial data is infartnation which generaity cannot be given to either the public or the subject ot the data. Our <br /> purpose and i�tended use ot this information is to annually update our records and records af ather gavemmantal agencies <br /> re uired b law. If u refuse t s I the�nfartnation, e a lication ma nat be issued. <br /> Applicant's Signature: Date: �(/it�, !{�� <br /> last Updated: 03-01-2011 <br />