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JUN-24-2611 07:20 From: To:9522494616 Pa9e:1�1 <br /> City of Qrono <br /> . ` Building Permit Application for Internal Work <br /> ' (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: pe�i�number: �d�/--DD��S <br /> O�O�O Grystsl Bay, MN 55323-0066 Date received: lo'zy—�f <br /> o, <br /> Strest Address: Received by: <br /> �� G� 2750 Kelley Partcway Plan review fee: <br /> � � Orono, MN 55356 <br /> Total Fee: .3 7�I• �D <br /> Main: 952-249-4600 Fax: 952-248�616 .ci.orono. n.us <br /> This appiication form must be compieted in full and all required information must be submitted. <br /> Incomplete applications wiil be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �00 LP.a� �'� Drqu�n , �r� ��� <br /> Will this be a Para�de of Homes,Remodeters Showcase Home or other Display Home? ❑Yes No <br /> If yeb,a special evern pem7�71s required with Police Deparhnent and Ciry Couna!approval 60 days prlor to the event ShutNe bus service will be <br /> iequiled un/ess applicar►t demnnstrates suH'rcient on-she parking�s available. Non permitted events wiU not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: , <br /> Name: �v�S r <br /> State License# � (�G � 2,OS�l 3 a Expiration Date: � 3� <br /> Lead Certi�ication Number. Expiration Date: <br /> (for work on homes thaf were constructed prror to�978 <br /> Phone: (o l 2-Q�6 l- '"l�� � (office) (cell) <br /> Mailing Address: \23 v ��c� v City: ZtP: S 33 <br /> Contact Person: ��� �� 1�,� ' Applicant is: Contractor / Homeowner �arc�o�) <br /> Email and/or Fax: ' �q� s�,,� 5 ' <br /> PROPERTY OWNER INFORMATION: - <br /> Name: D� Lov�se: �v��1�Cw� <br /> Phona(day): A��.- ►��l�-�fo 3� <br /> Address: �vc� Lea� 5�«'�' C�tY�D�v�...� ZIP: SS 3S(� <br /> Email and/or Fax . <br /> PROJECT INFORMATION: <br /> Type of Project: Any ea�th movement may require <br /> ❑ Door(s) ❑ Remodel ❑Water Damage MCWD review&permits: <br /> Minnehaha Creek Wate�shed Qistrict(MCWD) <br /> ❑Window(s) ❑ Repair [�Storm Damage 18202 Minnetonka Blvd <br /> ❑Siding Q�Restoration ❑Other:(specify) Deephaven,MN 55381 <br /> Phone� 952-479-0580 <br /> [�Re-roof ❑Fire Damage Fax: 952-471-0682 <br /> � www.m'n e a e k.a� <br /> Overall Project Description: �� � r <br /> Estimated Constructfo� Valuation of Project(excluding la�nd) a 1 �S"pp /35 � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all infom�ation required or requested by the Building Department; <br /> Certifies that the iMormation supplied is true and correct to the best of his/her knowledge. The�pplipnt recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so,the staff has no altemative <br /> but to rejed it uMil it is complete; � <br /> Some or all of ths infoRnatien that you are asked to provide on this appfication is Gassified by State faw as either private or <br /> confidential. Private date is irrformation which generally cannot be given to the public but can be given to the subjed of the <br /> data, Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and �ntended use of t�is information is to annually update our records and records of other govemmental agencies <br /> re uired b law. If ou refuse to su I the information the a licatlon ma not be issued. <br /> Annli�ant'�Sianature: ( X l.. � , Date: �`1�,NA . ��. ZD�� <br />