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Sep 25 10 05: 37p mike schrader ; 763-274-1899 p. i <br /> City of 4rono � .� . <br /> Building Permif App�l�catron fc�r°' internal Vllork C�� <br /> (windows; doors, sidin re-'roof e � <br /> g� , tc.) <br /> Mailrng Address:. Permit number. , <br /> '��.� PO Box 66 b/Q:-DZ7 D a� <br /> Q � Crystal Bay,.MN 55323-0066 Date received: g� 7 <br /> �a StreetAddress: Received by: <br /> �,. �p 2750 Kelley Parkway Plan.reviewfee: <br /> � oS Orono,.MN$5356:. <br /> Main: 952 249�600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: l�:�d,� <br /> This application form must be compfeted in fiull.and al! required information must be submitte <br /> Incomplete applications wiR be tetumed. (P/ease print) <br /> GENERAL 1NFORMATION: <br /> Job�ite Address: d <br /> VVifl.this be a Parade of Homes, Rer.riodelers Showcase Home or other Dispiay Home? Ye . No <br /> !f yes,a specia/event permit Js required wifh Polfce Department and Cify Councii approva!BO days prror No the evenL Shuffle.bus rvice wi71 be <br /> required unless.applicaaf demonstrates suR"icient on-sfte parking is evallab/e. Non-permitted evsnts will,not be al/owe <br /> CONTRACTOR/APPLICANT INFORMATION:, , � i ' <br /> Name: ) � t <br /> State License# o ; Expiratian Oate: > - <br /> Phane: / b` - office ce!! <br /> Mailing Address: „a w C' : � Z1P: 3 <br /> Contac#Person: ��y,� • <br /> —���� Appticant is: . on c o / Hortieowner lcir�ie o�a� <br /> Emaif and/or Fax: /! �aso��o� e,t <br /> PROPERTY OWNER INEORMATiON: <br /> Name: . ,e . �k� qh ,r, ' ' i <br /> Phone{day): . p j � <br /> Address: Ci : ZIP: <br /> Email:and/or Fax <br /> PROJECT INFORMATfON:. <br /> Type of Project: Any earth movement may uire <br /> MCWD,review&perm <br /> �Door(s) . ❑Remadel ❑Water Oamage <br /> ❑Window(s) [] Repair ,Minnehaha:Creek Watershed Dist (MCWD) <br /> . ❑StcRn pama�s � 18202 Minnetonka Blv <br /> ❑Sidin Deephaven,MN 5539 <br /> S ❑Restoration . [�Ot�er:(specify) Phone; 952-471-059 <br /> Re-roof : 852�7i-0682 <br /> � Fire Damage ahacr ek. <br /> Overnll Project Descriptian: <br /> Estimated Construction Valuation of Pro�ect.(ex g I nd) — <br /> APPLICANT ACKNOW�EDGEMENT: :- . '` ° <br /> • Agrees to provfde all information reguire .or�eq by e Building DeparEmerrt;i <br /> • Certifles.that the lnfo�mation supplied is true and ccrrect to'the besf of.his/her knowledge. 7he appllcant rec zes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff h o alternative <br /> • 'but to reject lt until it is caomplete; <br /> • Seme or all of the informaUon that you are asked to.provide on this application is classified by State law as f er private or <br /> corif'idential. Private data is information which generally cannot be given to�the public but can be given to th ubJect of the <br /> data: Confidential data is informafion which generally cannot be given to eifher the public or the subject o e data. Our <br /> purpose and irrtended use of this information to annually update our 'records and records of othe�govem ta! agencies <br /> r uired b taw. If. ou refuse fo su I he i rmation th a ti pon ma: nok.be issued. <br /> Applfcant's Signature, � <br /> Date: �"'7p <br />