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, + a � � � I , .. . . . <br /> Ci#y of C)rono <br /> Buitding Permit Application far in#ernal Work <br /> (windows, doors, siding, re-roof, etc.} <br /> Afiailin ttddress: �/�_�C�' <br /> j�/��O� PQ Box 66 Q��t numbar. <br /> � Grysta!Bay,MN 5�323-QO6fi DatB receivsd: �3 l� <br /> ��a r� a. SfreetAddress: Received by; <br /> � � � !*� 2750 Kelley Parkway Plen reYiew fee: ' <br /> {'��x�/ <br /> Orono,MN 5535fi <br /> Tata!Fes: �� ' � 7 (,� �/ �f`/S�i' <br /> Main� 952-24g-4600 Fax. 952-249-4616 www.ci.tuono_mn_us %� ! ' (<�/ `�-iy-/� <br /> This application form rnust be comp{eted in full and al{rr�uireci iRfosmation must be submi[ted. <br /> incomplete appiicatians will be returned. (Please print) <br /> GENERAL INFORMATIQN: 'I t r �� 1 �, f �� .,,, <br /> Job Site Addr�ss: .,2.(v�C'� K—�1� �t�('"�."�"t� f S�(31'12..�u�Q �`�'�, �7, <br /> WIU thls be a Parade af Homes,Remodelers�51 owcase Hcs r other Dlspiay H e7 es No <br /> �f yes,a special event permit is reqvired wfth Potice Departrne�t and Gty�nCtf approva!6Q day&Qtiar ta ihe event. $huttte bus Servfce witl be <br /> requ/rcd vnless applrca�demonshates sulficieM on-site parking Is ava�leble. hbn-pennitted evenfs will not be aflowed, <br /> CONTRACTaR i APPLlCANT W-F�O^RMATiON: <br /> Name: G"l p t'c�oY�.,JG�vY�e 5 �����1pv'� <br /> 5tate License# ��s+-� 4 c���t Expi�ation Date: �,.. 4_ ( '� <br /> Lead Certification Number: �� �}.-. Expiration Qate: <br /> (for wo�k on homes that were constructed prlor fo 1978 <br /> Phone: (�'y . (oiTice} ��,_ Q,� --3�i, �ceil) <br /> Mailing Address: 3 City �;,� ZIP: <br /> Contact Person: Applican#is: o tra r Horneowne� tctr��o�.k <br /> Email and/or Fax: y� _ � �Q� <br /> PROPEliTY OWNER INFORMATION: <br /> I�arne: � (� <br /> ��S. �.1t'�� � t'ti��¢� �'v�"''�.. h,r�f�. <br /> Phane(day): -t, a F 5--* ���-� <br /> Address: C-�j/? �• ?..,s�,�" S-'t:' City��.(�.iS �(�ZiP: ���-{j,�, <br /> Email and/or Fax �,r.�� �'y�p� y�-- U1(1p�f t�{�('c�YhWLe.!"� Mtlrw. � C( <br /> �. . •GQv►� <br /> PROJECT INFQRMATION: <br /> Type of Projoct; Any earth movement mey require <br /> O Daor(s) ❑Rernodel �Water Damage MCvuD neviaw S permtts: <br /> ENinnehaha Creek Waiershed District(MCUVD) <br /> ❑YVtndow(s) ❑Repair ❑Storm Damage 182�2 Mnnetonka Blvd <br /> Rastoratian Deephaven,MN 55381 <br /> ❑Siding ❑ ❑Other.(speGfy) <br /> Phone� 952-d71-0590 <br /> ❑Re-roof ❑Fire Damage Fax� 952-47'1-0fi$2 <br /> www.m f n neh a hacreek.ar� <br /> Overali Project Description: ' ,� " � <br /> E,.stimated Constructian Yaluation of Project(excluding land) $ � `�= <br /> APPLICANT ACKN011VLEDGEMENT. <br /> Agrees to pravida afl information requjred or raquested by tha Buitding Department; <br /> � Certifles that the information supplied�S true and carrect to the best of hislher knowledge. 7'he applicant recognizes that they <br /> are soiely responsibie for subm'rtting a complete appilcatlon being aware that upon faiiure ta do so,the staff has no attemative <br /> but to reject it until it is complete; <br /> s Same or 814 of the Snforrnation lhat you are asked ta provide on this appSication is�tassifiad hy State law as either private or <br /> confidential. Private data is information which generelly cannot be given to the public but can be given ta the subjecl of the <br /> data. Confklential data Is lrrfarmaUan which generally cannat be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information ls To annualty update our rscartrs and records of othe�governmental agencies <br /> r uired b law. If u refuse t su th info ation e a NcaUon ma not be issuad. <br /> ..--`' � ' J7 <br /> Applicant's Signature: ,��-r- � 6� ----- .^ Date: y/,)�'�.CJ/ � <br /> Casi Updated: 03-01-2ts1 i <br />