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I <br /> � �- • . . � . .. <br /> .. . ..... � . .I .. . ' . <br /> City +�f Clra�a <br /> Bu�ldtt�g Permit appiication for fn#erna( V�ark <br /> (windaws, doars, siding, re-roof, etc.} <br /> ���� h�iaitirtg Adriress: �� .� � <br /> ����� RO Box 66 Pam+if number , <br /> j Crystai Bay,MIV 55323-0�6 Rate tsceived: --/ -- <br /> ��l� � _� a. � Sfreet pddiess: Rereived by: �i/►,(�L L <br /> `�.�a {'' Gti� 2750 Keliey Parlcway PlBR r8Y18W#�: �' �i�;' '�('Lk�'L <br /> ��.�o�� Orono,Mhl 5535fi _ _ ,-� <br /> _ ,� _ � � , s� <br /> -_-- 7`otai Fes: _ , , <br /> Main' g�a2-2d9-4fi0Q Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be campleted in full and ali required information musi be submitted. <br /> incamplete applic.�tions wit!be retumed. (Please print) <br /> GENERAL tNFURMATiON: }` 1 �, � <br /> Job Stte Acidress: �,(A-7C� K-2 1�{ �r�("6e..-ts�"«�t`�Q�y� � ��� <br /> Will this he a Parae#e of Homes, ftemodelers S owcase Home�d�o#hQr Display Hr,Fne? es No <br /> !f y8s,a speciai eveam pennit is rsquired wfth Police Department and Gty Councrl approva�SQ tlays priar ia(hs avent. Shuitle pus sarvEc wd7 be <br /> requlred unless applrcant de�rwnstrates s�ierR an�sha pa�kking is avaNebte. Non-pemritted cvertts wdf nof be allowed. <br /> CONTRACTOR i APP!„lCANT 1WF�'3RMATlC?N: <br /> ;Vame: ��to c"c��t.� .,�tM e.S ���Y�i�Y� <br /> _________ <br /> State License# �,ps-��^ _ Expiration Oate: �„.. 4.- � "L <br /> Lead Certification Number. (� �}- Expiration Date: <br /> _ __ _ <br /> (for work an homes that w�ne canstruct�ed prior Fo t9T8 <br /> PhAfle: (�'3,_ (office} �'�. . g'� -'"�SZ.C.� 4Ce11� <br /> Maiteng Address: �'j CiYy �� ZIP: �-��� <br /> Contaet Person: Applicant is: o tra Homeoumer ccxcieone} <br /> Ernai!and/or Fax: y�_ C�yy,,� <br /> PROPERTY OiAINER IIi1FaRMATIOFt; ��� V�'.l,V`.�..._ <br /> hame: �'�_�-� � t�. � E�r+-�` <br /> Phone(day): � _ __---- <br /> .S�-- �� �} <br /> adaress: ��_LZu-?' 3��''' S 7: c�cy<=t.__tt.�i,..�fi�r-��zrP: ,�S�{1.� <br /> Email andlor Fax ' ' ' <br /> _ _._._ n <br /> PftOJECT INFQRMATIQN: <br /> Type of Project: Any earih maverr�ent may rgquira <br /> D Ooor(s) ❑Remodai ❑Water Damage A�ICVYD review&perm�s: <br /> Minnehaha Creek Watershed Qistrict(MGWD} <br /> �Window(s) ' ❑Repair ❑Storrn Damage 18202 Minnetonka Blvd <br /> ❑Siding ' ❑Restara0on ❑p�her_(specify� ' �ephaven, MN 55391 <br /> � Phone: 952-471-059[1 <br /> ❑Re-roof � ❑Fire Damaga Fax: 952-471-0682 <br /> wNnv.m innehahacreek.orq <br /> Qverail Project Description: �y��5j,� ���,�j• ' <br /> Estimated Gonstruction Valuation af Project{excluding tand) � � (, ,:.-�-- <br /> APPLICANT ACKNt�WLEdGEI1�Eh(T: <br /> � Agress 10 pravida aif information requirecf ar requasted by the Buikiing Departmen� <br /> � Gertifles that the information supp�iad is true and correct ta the best Qf his/her knowledge. Yhe appi(cant recogni�es that they <br /> are sotety respartsrbte tor sc�brts�tting a campiete a¢pltca[ku�betng aware tttat upon faiiure to da so,the staft t�as no a(temative <br /> aut to reject ii untii it is compiete; <br /> � 5om� of a{t ot th@ irlfOrmation that you are asked to provida on this appiication is c]assi6ed by Stata taw as eiEher pnvate or <br /> confidential. Priva#e data is informatiart which generally cannvt be given to the pubfic but can 0e given to the suaject of the <br /> data. Confidentia! data is in#ormativn which gene�a{ly�annat be given tt> either the pubEic or ttte subject of the data. Qur <br /> purpose and intended use of this inforenation is to annually update our recartis and records of ather govetrtrnent�agemcies <br /> re uirad b law. If Qu refuse s�pl�ha info atio , e a lication ma not be issued. <br /> Applicant's Signature: � � t��� Dato: '�—� ��C3� � <br /> East Updated: U3-0i-2dii /�� - <br /> � <br /> I ___---...T_... __._ _ _........_w..._.._...__._ <br />