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C ity of C3r�n�► <br /> 8uilcfing Permit App�icatic�n for fnte�rr�al V{/ark <br /> (windows, daars, siding, re-roof, etc.) <br /> Mailin ,a�ss: _ �/ -00�7 <br /> ���,�7. PO 8ox 66 Permi#number. <br /> l��l Q Crystal Bay,MN 55323-00&6 { t3ate ret�eived: � <br /> � � Re�eived by: <br /> + i' �. StEeet t�dttress: <br /> \�.� ' � `�' 215b KeNey Parhway Rlart reView#ee: � � " ;r_� <br /> �`��st��p8�� Orono,MN 55;i56 <br /> " ` � Totai Fee: . � � (,/ <br /> Main: 552-2d9-46{10 Faz: 952-249-4616 v_,n�.tiv.ci.orono.mn.us . � � .,' <br /> This appficafion form must tse c:vrRpleteti in full and ali rc�quired info�mation must be submittsd. <br /> incompiete applica#ians wiN be return�d. (Please print) <br /> GERtERAL INFORMATIaN: <br /> Job Site Address: S`�p .�5, t� ,'� J� �"� <br /> > <br /> Will this he a Parad�ef Homes,Remodel�rs S owcase Hom r other Display H s? es No <br /> ►�yes,a speciet event,oam�eK is required wtth Potice Departnrent aRd Gty Counci(approvar 60 days prior:o!ha event. Shuttte Gus servi wftl tsr. <br /> requved unless applicant��emonsirstes srifirrenf on-srte parking ts avaBaMe, lHon-�rermiKed avents w�7t na2 be ailoweo'. <br /> C0�17RACTtJR/APPI.lGASN7`t1J~F�U—F�3MA'F1bN:/� �s. ..�.,, <br /> Name: ��"lo�'ot4ri,_1GttMeS �-�C7Y����'GtfsllpY� <br /> State License# ���+-� S c��� � Expiration Date: �.. � .. ( "�,� <br /> Lead Certification Number: �} f}– E�iration Date: <br /> (for work on hames that were constructed prior fo?978 � <br /> Phane: (�'�,_ _ (ofGce} ��- Q'�"'?�, Z. (cet#) <br /> Mailing Address: "�, � City ,C_ G.t� Z{P: C'l'"�,�"G!__ <br /> Cantact Person� Appiicant is; o kra Homeow�er �c�iea,e} <br /> Emait and/or Fax: y,� _ <br /> PROPEfiTY OWNER tNFORMATION: <br /> Pfaene: `�'"� �__�._����.�` �.�r*.� <br /> __-- _ _--___ <br /> Phane(day): -L � � <br /> Address: �Dbh W. 367'' S'�:"' c�iv����.ss� ��ICz«: �S �tlk___ <br /> Emai! and/or Fax ' <br /> _� ___ __ � <br /> PR�.IECT INFQRMATION: <br /> __ _-- — -- <br /> Type of i'roject: � Rny earth movemenf enay require <br /> ❑Door�s) ❑Remodel ❑Water Damage �CW�review 8 permits: <br /> NAinnehaha Creek Watershed Oistrict(MCWD} <br /> ❑Windowjs) ❑Repair ❑Storm Qarnage 182tf2 Minnetonka Bivd <br /> ❑5iding ❑Restaration ❑Other:{speeify} �eephave�,MN 55391 <br /> Phane- 952-471-053� <br /> [�Re-roof ❑Fire Damage Fax: 952�71-0682 <br /> www.m[ntiah�har�reek.oro <br /> Overafl Project Descrtptian: ,,t' u ,.,�, ' <br /> ��_._. _ ._._.. _ __ ... <br /> F_stimat�d Ganstructton Valuation af Project{exciuding iand) � (,� '(�.,�?._'" <br /> APPLICANT ACKPlUWLEDGEMEtVT: <br /> Agrees to provida ai{information rsquired or requ�sted by the Building Departmen� � <br /> i Certifies that the information supplie�d is trt�e and corred to ttte best of hisJher knowl�dge. The appliGant r'eC�gnizes that they <br /> are sa�efy resperosiht�Far sutsm"rttirtg a comptete appllcatlon betng aware that upon failur�io do sa,the staff has t'►o altemative f <br /> buf to reject it until it is complete; <br /> � Soma or a1t of the inforrnation ti�a#you are askad ta prov�de an this�pficatirin is classified hy 5tata iew as either private or ' <br /> canfidentiat. Private data is information which gsnarally ca�not be given ta the public but can t�e given to the subject of the <br /> data. Confidential data is infarmation which genera�ly cannot be g�ven tcy sither the public or tt,e sutsaec:t af the data. Our <br /> purpose and intended ust of this information is to annually update a�r records and rECords of otheC gOverntnental agencies � <br /> re uired b law. li ou refuse ta supply t i� rtnati n,tfia a lication may not be issued. <br /> - <br /> _ ,.'" �'7 <br /> Appliea�Ys 5ignatu�e: _ r �`�� �/�� Date: 7"�����c� <br /> Last Upda[ed: 43-01-201 i � <br />