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�ity of t�rano <br /> 8uild�ng Permit AppliCatian fior Interna{ Work <br /> {windows, dr�ors, siding, re-roof, etc.) <br /> ���----. A.�iiling Address: petmit number �D/ a-(]'� g' <br /> ��d,(�.� PO Be�c B6 � <br /> �l� p� (�\;, Crystai BaY,MN 55323-0066 Date raceived: �/`�/ _02 <br /> t <br /> 4`� � ,;�;. s.� Street Address: Recefved bY: '�YLCA.�� <br /> 1, ,� ^ ��' 27b0 K Iley Partcway � Plan reYieW iee: <br /> ��ax �,s� Qrcmo;MN 55356 � _.._ <br /> -,:.,k'EiH��> ,- <br /> --..-._-- TDtar�FEB: 2 ; ;.� �% r_��: <br /> Ivlain: 952-2d9-d6t10 F2x: 952•�49�4618 wwrw.a.orono.mn.us � _�.f i ``' ,�� • Cr I�S4 <br /> Thls application form must be completed in full and all required inform�tton musi be subrnitted. �i-,y-�Z <br /> incompiete appHcatians wili be ratumed. (Ptease print) <br /> GENERAL lI�FURMATIt}N: �t i <br /> Job Site Address: .,�,frs�C7 K-P�1�2�{ �rx[`�'�5�0�2�u�Q �t'+,�" �/.5 <br /> Will this be a Parade ei Homes, Remadele�awcase Hama�dr ather Display Ho ne� es ^[� No <br /> If yes,a special even!permit!s required wkfr Podice De,aartment and City Council approva!&D deys prinrl�1he evani. Shutile bus ServiCe wi//ba <br /> requJr�d untess applicau�t demonstrai�s scrtf+ciertt on-sifa perking Js avail8ble. Non-permrtfed evvnfs wid not be attow�d. <br /> CONTRA.C70K t APP�tCA4tT INFURMATtt3i�t:J� _{._.��' y.� <br /> Name: �""'ya Pc�t>ri.�Vt'1 e� �1^�.� t �'1�t.�1 IQ�Y� <br /> Sfat�Lic�nse# Expiratian Date: �_ t� � '� <br /> Lead Ce�tification Number. (� �-. Expiration Date: <br /> (for work on homes that were construcfed prior!�o?9TB __._._ <br /> Phone: L�'3 - toffice} j'�- Q',�' - �.L.� icetl) <br /> Mailing Addrsss: '?�, City ZIP: ��� <br /> +� �t.ci+� <br /> Cantact Person_ ,4ppiican#is: o tra r Homeowner tcrrcae o�}� <br /> Emeif andiar Fax: �_ ��y�.,,� <br /> PROPERTY OWNER INFpRMATION: <br /> �lame: � �'b_�.�� � !'ti���ev�P.�rt' ��rrt F...__ ____ <br /> Phone(day}: �L-►� �;i—�.4.'s�• �'S'4�`6� --------____ <br /> Address: �Ot7��, �+,�'s� 5-r' City..r',-�-'�.5 rdf,�/ ZiP: -�,r-'S �t�,� � <br /> Email a ndtor Fax �(�,t.,�y� '"'i�,y��;e,�-- yl(�0.f�tx��D f�.Yri��� �,�.�G( � C.�CJw� <br /> RROJECT INFORMATION: <br /> Type af Projact; Any earth moverncnt may sequise <br /> �Daor(s) ❑ftemodei ❑Water Osmage ��p���&p��mits: <br /> Minnehaha Creek Watershed Districi(MCUVd) <br /> Q Window(s) ❑Repair (]Starrrt damage 18202 Minnetonka Bivci <br /> [yeephaven, MN 55381 <br /> ❑Siding ❑Restaratian ❑Other:(specify) � p}�one� 952-d71-0590 <br /> ❑Re-roof ❑Fire Qamaga Fax: 952-471-4682 <br /> wtivw.m irLehahacrcek.ar� <br /> t�veraR Project Dascriptlon� �,.r, (j=„�. <br /> Estimated Canstruction Valuation af Pro}ect(excluding 1an�} � �::�, -- <br /> ___ _ __ -- __- <br /> APPLICANT ACKhlOWLEDGEMENT: <br /> Agrees to pravide all iniarmaBon requfrsd or requested by thg Buitding DepaRmen� <br /> � Certifies that the info�mation suppfied is true and correct ta the best of hislher knowledge. The app{icani recognizes that they � <br /> are soietiy responsible for submitting a comptete appricatl�n befig aware that upon failure to do so,ttte staff has no altema Cnre ! <br /> but to reject it until it is cnmplets; <br /> � Swne ar afi of t�e inforrr►ation thai yau are askad to provicie on this appticatlon is ciassiGed by State taw as eifher private tx <br /> confidential. Private data is informatian which ganerally cainnot be give�to the public but c�n 8e given to the subject tyf the <br /> data. Canfidential data is informa�a� which generally cannot be given to either the pubiic ar the su6ject of the data. Our <br /> purpose and intended use of this information is ta annually update our records and �cords of oiher govemmental agencies <br /> re uired b law. If u refus o su the ir�fo tion,the appiicati�n ma not be issued. <br /> Applicant's Signatu�e: r�� Date: �- �3- '�.__ <br /> R.ast Upda9eQ: a3-01-2011 � `�/; <br /> ; <br />