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City �►f C�rana <br /> Buiiding Permit Application far Internal Work ' <br /> {windows, doors, siding, re-roof, etc.} <br /> �-�_ lvlai�ing Address: P�if numbar. �Q/a '��g <br /> ���i,.d,�\ PQ Box 66 n � <br /> � 1 Grystai Bay,MN 55323-0066 s Date received: 7 -/3— <br /> �T��,�. <br /> t a. StreetAddress: Received by: � <br /> ece <br /> ��'.�� ��G�' 2750 Kelley PaHcway � Pian reView#ee: <br /> �ar��H�+�� Omno,MN 5535& � <br /> - -=- � , , , 3 f <br /> Main: 952-248-46(1� Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: ; l -j � _ C`` s ' <br /> This ap�licatian form must be corr►pleted in full and al!required infcx[nation must be subrnitted. �i � y-i 2. <br /> Incomplete applicatians will be retumed. (Ptease print) <br /> GEt�ERAL INFbF2MAT10N: / <br /> Job Stte ttddress: S�D � �� �T 2-�v <br /> WiU this he a Parade of Homas,Remodelers S Qwcase Ho r ather Disptay H e? es Na <br /> If yes,a special event permii is required wrtlt Police bepa�trnent end City Couaci(apfxovalBQ days pnor Zo the evani. Shuttle bus service wilf be <br /> mqulred unl�tss applicant demonstretes sulircient onaite parkurg/s avaUedle. Non-permiKed events wiff not be allawed. <br /> CONTRACTOR t APPLlCANT lN�ORMAT1t7N: <br /> Name: �.'1arc�or.�a.�rt�S �S�l�c�loYt <br /> Siate Llcense i� Expi�atfcsn Uate: <br /> Lead Certification Number: .�~ t' � 2 <br /> j�} �}-- Expiratjon Date: <br /> (for worlr on homes that ware constructed prtnr to 7978 <br /> Phone: (��, . (o�f'�ce} ��- g''� ""2��C� {ceN) <br /> Mailing Address: '� City (�[,,t ZlP: �-�-� <br /> Contact Person: Applicant is: o tra r Nomeorvner (Cfrcla Ono� <br /> �maii and/or Fax: �. � C�� <br /> PROPERTY OWNER INFpRMATfON: �(� <br /> 1�4ame: �� �Y�� � ��+a�.E f'-v�.rt� Y�".�,�.� <br /> Phane(day}: �-Z � � <br /> Address: t,�,1. 't'� Cit <br /> soc�� 3� S-i:' v'Q-�.r�c t.s.�r�tC z�P: �-S�{�.i� <br /> Email andlor Fax ��,�h "�t.�,����-- ��t�b ru��,�� ��� G� b��m <br /> PROJECT INFQRMATION: <br /> 7ype of ProJect: Any earth movement may require <br /> ' MCWD reviewv& ermEts: <br /> �Daor(s) ❑I�emadel ❑Water Damage IVlinnetiaha Cresk Watersh d District(MCWd) <br /> ❑Windaw(s) [}Repair ❑Storm Damage 182Q2 i,ninnetonka Bl�d <br /> ❑Siding ❑Restoration ❑Other:(specliy) �eephaven,MN 55391 <br /> Phane: 952-471-0590 <br /> ❑Re-roof I ❑Fire Damaga Fax: 952-47�-0682 <br /> w�yy�+.minnehahacreek.or� <br /> Overall Project Description: �N, l� („1,,�,�� ��:-: <br /> Fstimatad Construction Valuation of Project(excluding Fand} y �f��,^�� _.-- <br /> APPLICANT ACKNOWLEDGEMEPtT: <br /> �- Agress ta prrnide a11 infamation required or raquested by the Building Department; � <br /> i Certifles that the information supplied is tnle and correct to the best of his/her knowledge. 7�he applicant recogni2es that they I <br /> are soiely responsible for submrtting a comptete appllcallon being aware that upon faifure to do so,the staif has no altemative <br /> but to rejeci R until it is complate; <br /> � Some or a11 af the tinfotmati�on ihat you are asked to prov�de on this�pptication is ctassifieci by Slate iaw as aither private or <br /> confidential. Private data is informatian which gsnarally canhot be given to tY�e public but can be given to the su6ject of the <br /> data. Confidential data is information which generaly cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this i�f4rmatian is to annually update our records and records of other governrr�nt� agancies <br /> re uired b Iaw. If u refus to su the irrForrnatian,the a {ication ma not be issued. <br /> Applicartt's Signature: � 1 �'`''e--� _� pate: ��� ��/`� <br /> tast Updated: U3-0i-20i S � <br />