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� � 3 �-� .a� <br /> J <br /> Ci#y t�f C'�rono <br /> Buitding P�rmit Appticatian for Internal Wc�rk <br /> {windows, doors, sidin.g, re-ro€�f, etc.} <br /> ,�Q_`\ Mailing Address: Permif number. b l ���� <br /> �Q4� 11�'�\ c�r�i e y,�nr��sza�s � �ata receNed: /�--1-1.� <br /> �! �� � <br /> ��� �� % �,j� StreefAddress: � Receivedby: <br /> '`��.�, ��'���� �'�� 2750 Kelley Pa�icway � PtaR review#ee: <br /> \tq'fsaeio8�� Oro�o,MN 55356 `"" <br /> --= �Total Fee: <br /> Main_ 952-249-4600 Fax� 9§2-249-4616 �vww.ci.orono.mn.us <br /> This application form must be compieted in fuil and all required information must be submitted. <br /> incomplete apptications wiil be retumed. (Plesse printJ <br /> GENERAL ttJF�F2iUlAT10N: rj n ,� 3 ,j <br /> Job Siee Address: _��U �-P�Lt� �i'�,(`�.�[ _���t Ott��U t�' C,�Ni 7 � <br /> Wili this 6e a Parade of Homes,Remodelers S owcase tlomo-dr other Disptay N e? es Na� <br /> �f yes,a spacia!event permH is required wtth Police 1}epartment and City Gouncri ap�raval8t?days pnor to[he eveni. Shutt(e bus serWce ta�f be <br /> rnquired u��css applicant demonstretes sutficient onsite parkr»g is aveAe4�e. Non-permiKed events wi17 not be alRcnved. <br /> CANTRACTOR!APPl�fCASNT lNFORMATlDAt: .J.�� <br /> Name: �"loi'�sori�i�►�t e S �S�Y'`t�.t..h t�y': � _ __ <br /> State License# �C,S-�,, 4��1 ExpiraUon Date: ��_�. <br /> Lead Certification Number (�}��}- Expiration Date: <br /> (for work on hames fl�at were constrLcted prio�i'Q 1978 <br /> ?hane: �j L�3 • t{Z�l- '3 t L� (office} ��. g'$q "��,t{ (ce{;) <br /> _ _—_--- <br /> �fiailing Address: �-p • (�? '?y City . �.` .���Z1F:��� <br /> -�-- <br /> Contact Person' _ Appiicant is: o tra r Homeowner �crr�aet�r,�} <br /> Emait andtor Fax: ` Y�-�G�n•,•teS _CC3�'+� <br /> Pi20PE12TY dWNER INFpRMATION: n_ �� t� <br /> Name: � �'� _ v � Y^�'�-t �Ar�.i�.. -- <br /> � �_.t'� +z E'v�.�C` <br /> - ----_._---- <br /> Phone(day}: �,, �., ��r-� <br /> Address: ��,� c,�.�. 3��" s-�;- cay.�-��p�.,�-zr�: �S�{(b _ <br /> Email andlor Fax r <br /> Pf20JECT INFQRMATIQN: <br /> .- ------__------� -- - _ -______ <br /> Type of!'roJect: I Any earfh rnov�ment may raqaere <br /> ❑Daor(s} ❑Remodei ❑Water Damage �C��view&permits: <br /> Minnehaha Cmek Watershed Oistrict(MCWD} <br /> �Window(s) 'i �Repalr []Storm Damage 18202 Minnetonka Bivd <br /> ❑Siding ; ❑Restoradon ❑Other:(sp�cify) C�eephaven,MN 55391 <br /> Phone� 952-471-0590 <br /> ❑Re-roof ! ❑Fire Damage � Fax: S52-d71-OF,52 � <br /> �.m6lnek�aharxeek.orq <br /> ___._ <br /> CJverallRrojectDescription: �,H, �g .-Lf -cS�[} �,J�.=` �?• _ <br /> �-` - <br /> r <br /> Estimated Construct€on Valuation af Project{excluding lancf) m;���,�dp <br /> APPLICANT AGKN�VNt_EDGEMENT: <br /> � Agrees to prowida att iniormatian req�bred or requesteci by ihe 8uiiding Depactmen� <br /> Certifies that the information supplied is true and carreci ta Nte best of hislher knowledge. The appiicanE recogrtizes[hat they � <br /> are solety resportsrble(or submitting a comptefe applicatlori beir�g aware tha#upon faifure to da so,ttie siaf€has no aitemative � <br /> but tn reject it untii it is complale; <br /> . Some Or aVS of the informaiion that you are asked tn prov'�de on[his appficauon is classified by State law as eitfier private or � <br /> confidential. Priva#e dala is lnformatian which generally cannoi be given to�se public but�n be g;ven so the subject of the ' <br /> data. Canfidential data is information which generally ca�not be given ta either the pubtic or the subject�f the data. Qur � <br /> purpose and intended use of this informa6on is fo annually update our necurds a�d records ot othe�governrnental agancies I <br /> re uired b law. If u refuse sup the icaformation,Ihe application ma not be issuad. �; <br /> -- � - <br /> __- <br /> � , <br /> ,r- 5 ^'� � � <br /> ApplicanYs Slgnature: ` �'' ' ___ Datc: � �f�" ���-��!� <br /> �asf Updffied: 03-4i-20i i <br /> ', __�__..----------.__..... <br />