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j t . <br /> Gity of C3rc�no <br /> Building Permit Apptication for Interr�al Wor�k <br /> windows, doors, siding, re-roof, e#c.) <br /> �---- Mailing Address: <br /> ��,�� PO Box 6fi Pem►it nurnbsr. <br /> � Crystal Bay,MN 55323-0066 pat�received: �/� <br /> i �� ",ia <br /> a. Sf�eetAcldress: Received by: <br /> ��,�, U% 2750 Keliey Parkway Piert reYiew fee: . ' <br /> �vx�xQ�.� Orano,MN 55356 <br /> —_ - Tatal Fee: f.j _� �- G"_ ,��' <br /> Main: �'a2-Zd9-4&00 Fax: 952-249-4616 www.ci.orono.mn.us � �� -' � �'�`�`i <br /> ThiS appliCqtion form must be cornpleted in fuil and all required inlorrnation rnust be submitted. `>- i y-/L <br /> incompiete applications will be retumed. (Please print) <br /> GENERAL INFORMATION: { / n ( �� � / <br /> Jab Site�0.ddress: �.�a�C� �Q�{1'�-{ �('�LJ��r"1U (S�0!'���.i.0 t�..'OY�cxC)`� �'''���'�T ���� <br /> Wi0 this he a Parade of Homes,Rem4delers SHowcase Homc�r other Display H e? es --�'No <br /> !f yes,a speciat event pe�reit is required wrth Poltce Depertrrient snd Cfty Coutta(ap(xovat 60 days prior to tha everii. Shuttte�us Se+viCe witl be <br /> requtred unless ap�lticant demansYrates suHicierrt onsite parking Js availaWe. Non-permitted events wif!not be allowed. <br /> CONTRACTOR/APPI.lCANT lhIFORMA7lOhl:/� <br /> Name: G"1nt'c�pt�.-�,im�5 �--�r�S��eaY� <br /> State License# p Expiration Date: �.- t_ t ~� <br /> Lead Certificatian Number: j� �}- Expiration Date: <br /> (for work on homes that wero constructed prior to 1978 <br /> Phone: (�'�, . (oKce} �Z.. - �''g� " Z,'.t4 icel#) <br /> Mailing Address: 3 Ci[y �;,� ZIP: ����_ <br /> Contact Person. Applicant is: o tra r Horneownar �cir��e a�o3 <br /> Emait and/or Fax: n - CC3y,.�. <br /> PROPERTY OWNER in[FQRMATION: �/� <br /> Sdame: �'� S � Y��+z�G'_rn.�' 'i�('.��.� <br /> Phone(day): L , �_ <br /> Address: ��j� t�.a. ^.S(�'�' �C-7:' City�`�L�.S.�d��ZiP: S".j�(�,�i <br /> Email and/or Fax �,h,�yh `����- ��,a„�b rK.mw�,e.rY� �p�,,y�� G i b•G�f7m <br /> PROJECT INFORMATION: <br /> 7ype of Project: Any eartA movement may require <br /> ❑Daor(s} ❑Remodel �Water Dsmage MCWD review 8 permits: <br /> Minnehaha Creek Watershed Distrtct(MCWD) <br /> [�Wirxiow(s) ❑Repair []Stortn Damagc � 1E3202 Tvlinnetonka$lvd <br /> ❑Siding ❑Restoration ❑Other:(speclty} Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> �Re-roof ❑Fire Damage Fax: 952-471-Q682 <br /> www.minneh aMacreek.orc� <br /> Overall Project Description: �,,,,�t,� �;+:n," j��� <br /> Estimated Construction Valuatio�af Project texcluding tand� ��� <br /> APPLICANT ACKMOWLEDGEMENT: <br /> Agrees to prQvide aN iirfamation required or requested by the Building Departmenl� <br /> � Certifles that the information supplied is true and correct to the best of his/her knawledge. The applicant recogni2es that they <br /> are sotety respvnsrbl�for subm�tting a complete appttcatlon betng aware that upan fai�ure to do so,the siaff has na a(tema tive <br /> but to reject it unti{it is eomplate; <br /> ! Some or aIt af the information that you ane asked to provide on Ihis appiicat�on is ctassified by State taw as either private or <br /> canfidential. Priva#e data is inforrnation which generally cannot be given to the pubGc but can be given ta the subjecl of the <br /> data. Confidential data is informadon which generslty cannot be given to either the public or the subject of the data. Our <br /> p�rpose and intended use of t 's infoimatian is to annually update our recards and recvrds of other governmentai ager,cies <br /> re uired b law. If u refusa su th informatia e application may nat be issued. <br /> --. _ --- > <br /> Applicant's Signatu�e: -2,. '+ t�. �.-� Oate: ���!��� �`�j` ` <br /> tast Updaied: 03-01-2011 <br /> � �J <br />