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, Y <br /> �ity of Qrono <br /> Buiiding Permit �plication for In#erna{ Work <br /> (windows, cloQrs, siding, re-roaf, etc.) <br /> Mai�in Address: <br /> r'----_"- 9 Perrnit nurnErer. "'� <br /> +f�/'`�,0,�.� PQ Box 6fi <br /> � # � Crysiai Bay,MtJ 55323-40fiEi Date received: ��l <br /> �` ' �- Receiued b <br /> �4.� .,� e.� Sfreet Addr�ss: y� � <br /> ���.� 4 ' . GC`'� 2750 KeUey parkw�y Pian r�YieW fee: /V�F�� "f�-z;: .;_ <br /> ���H��'� Orono,MN 553�6 <br /> �� <br /> �_ Totai Fce: � �.� r <br /> _� _ � ; <br /> Main: 952-249-46tip Fax: 952-249-4616 vutivw.ci.�ono.mn.us � ' £ <br /> This application farm must be r.ompteted in full and aii reqwred informaiion rnusf be submiC <br /> ea. <br /> incompiete applicafeorts witt be retumed. (P/ease�rir�f) <br /> GENERAL IMFORMATION; � ��� � � � � <br /> Job Site Address: <br /> Will this be a Parade ot Homes,Remodelers S owcase Hom r other Display H a? es Na <br /> tf yes,e speciat event pem+it is required wXh Pdice UepartmerN snd GifV Councif ap�wvva}60 days prior to the event. S !e bu&sctivice svill Ge <br /> required unfess applicrarN demonsUates sufftciertt orn.sile parking ts auaUable. Non-perrnitted events w'd!raot be a!(oweA. <br /> CONTRACTOFt/A,QP�.ECAI+!'C t�tFORMATIt)l+t: <br /> Name: �`1Q t'c�.t>t'�-�im e S ���Y'1�.c'�1�►r'� <br /> State License# �O_�+��c��_ Expiratipn D�te: �.. (,.- ( 'Z, <br /> Lead Certification Number_ � �.-. Expiration Date: <br /> (tor work on homes that wrere constracbed priw to 7978 � <br /> Phane: L,�'�s - - (office} ��. �'+� — �, (cel1) <br /> Mailing Address: , . '3, City �;,� Zlf': �{'-��-t�� <br /> Contact Person: ' Applicant is: o tra� Homeawn�r �c�rtiao�e}r <br /> _._._._._ <br /> Emaii andlor Fax: y� _ <br /> PROPERTY�WMER INFORMATION: �(� <br /> Alame: �'"� 4�[�-�t_�_Yt��¢.�t'v�..rt' �(�'.i.v�.� <br /> --_. <br /> Phone{day}: � � <br /> Adar�ss: ��-,�`,t�___w • 3�`ri' S'f.' c�ty`��t.s__r��kziP: �S �El,b_- <br /> Ernaii andtor Fax — <br /> . <br /> PR{}JEGT tNF+QRMA7fON: <br /> _. _ � _ -- _ _.__ .-- <br /> Type of Projec� Any eacth movement may require <br /> MeWD review 8�permits: <br /> D Dnar(s� ❑Remodsl ❑Water Damage ���nehaha Creek Watershed DishiCT(MGW D) <br /> []WfnclowtsJ ❑Repair Q Storm Damagc t82t72 Minne#onka B(vd <br /> ❑Siding ❑Restaration ❑Other:(speCiiy} � �eePh�ven,MRt 55351 <br /> Phone: 862-471-059€� <br /> ❑Re-roof � ❑Fire Qamage Fax: 932�7'1-Q6$2 <br /> �i uvww.minnehahacreeic.arst <br /> Ov�rall ProJect Descriptlon: �,.t,SL/ �';�ic� �{. ��r�' �r� �� - r � ���. -_ <br /> �etimat�d Const►uction Vatuation af Project�+�xciuding land} � �J t,�? �. _ <br /> APPLiCANT ACKNOWLEDGEMENT: <br /> -- -�_ _.__._. <br /> Rgrsees to pravide att infamatlon�equired or requested by the Building€3epartrnen� <br /> � Cerlifies that the informakion suppfied is true and correct ta U�a best of hislher know{edge. 1"he applicank recognizes that they <br /> are saie3y responsible for submining a complete appilcatfon being aware that upan failure to da so,the staf�has no aftemaCive � <br /> but to re}ect it until rt is camplate; <br /> � Same or ati af Use fnfarm�tion tt�at yau are asked to pravide on this appticatioR is ctassified by Stsfe taw as eiffrar private or <br /> canfidential. Private data is informatian which genara{iy cannot be given ta the public but c:an be given to the subject of the <br /> data. Gonfidential data is infcxmation whlch generally cannat be given to either the pubiic or the subject of tne data. Our <br /> purpose and intended use of this infarrrration is to annually update our Fecords and records of other governmental sgencies <br /> re uired taw. tf refuse t u pf�+th i�,f tian, .e_a�pticaFion may na[ha issued. <br /> J--.. .. __... <br /> Applicart's Signature_ �ls E�ate: '�- � ��C�� <br /> East t3pda4ed: G3-0t-2a1 i f <br /> � II <br />