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SEP/01/2015/TU� ;0; 10 PM Elder Jones Building Fn� �'�, ��2 854 4909 P, 003 <br /> ' City of Q�-o�na <br /> � B �Id�ng Per-mit Applicat�o�n for In�ernal V'V'ork <br /> (windows, doors, siding, r�-roof, etc.) <br /> ��--�� ' Ma�ling Address: C-� _ , -�; ,. <br /> '��,0.(�.� PO Box b6 permit number. L�i�. ��7 <br /> '� � Crystal Bay, MN 55323-0066 Data reca�ved� "t I Z. l �� <br /> � r� � <br /> � =`�"i`"''„ Rec�ived by: �� <br /> ���,� ; �T�.�,;';, � StreEt Address: <br /> \�, ,i�°-;;i��,^.,� Gti� 275o Keflsy Parkway pian review fee: A <br /> ���s����s��o�.�i � Orono, MN 55356 ) <br /> `--�� Total Fee: r' l-- <br /> Main: 952249-4600 Fdx: 952-249-46"16 www,ci,orono,mn.us ,L�� ' <br /> This ap�icafion form must be campleted in fulf and a!I required information must be submitted. <br /> Incomp[efe applica�ions wi[I be reYurned. (Please prrnt) <br /> GENERAL INFORM' TION: <br /> Job Site Address: � � �f',1� �I l� �d n ��/'e ��,� �C.. <br /> Will this be a Parade of Homes, Remodelers Showcase Nome or other-Display Hon,e? ❑ Yes ❑ No <br /> !f yes,a specia/evertf p I rmit is raquired with Policc�Department and L`ity COuncr!�pprovaf 60 days prio�t0 thA evRnf, ShutUe bUS SENice w(!/be <br /> required unl�ss applieant dEmonsirates sufflcl�nt on-s/ie parking(s avallable. Non-permitted events wiu not be allo�ved. <br /> CONTRACTOR/APP ICANT INFORM,ATION: <br /> rvame: �'s� 3 Y S . G ti�/7 <br /> State �icense# �ella Northland -� ' <br /> PI�one: � �^��, 153Q0 25t1a.A.ve N. Ste 100 {ce�l) <br /> Mailing Address: p�ymOYlt�'1, MN SS44"7 z1�'� <br /> Contact Person: ��„ �,ic�BC�i45090 Ph. 763/745-140d �omeowner (Clrcle�ne) <br /> Email and/or Fax: <br /> PROPERiY OWN�f2 FORMA7I�N: � <br /> Name= <br /> Phone(day): � (. � ` <br /> Address' Y!�j �(,(, City:�4/E Q �Q f G ZlP: �S ,'3�' l.^^_ <br /> �mail and/or Fax <br /> PROJECT[NF�RM/�TIDN: <br /> Type Of 1'rpjeCt= - Any earth movement rnay require � <br /> _ _ MCWD review& permits � <br /> "� Door(s) ❑ R�model � ❑V1y�ter Damage 1 "�- <br /> , Minnehaha Creek W�tershed DiStricF(MCWD) <br /> ❑Window(s) Q ftepair ❑S�orm Damage �I 18202 Minnetonka �Ivd <br /> beephaven, MN 55391 <br /> ❑Siding ❑ Resforation ❑ Other: (speClfy) - � Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> j ❑ Re-roof ❑ Fire Damage � www.rninneha r k. r w__�J�� <br /> Overal! Project Description� (,� ,r( � � <br /> �— <br /> Estimated Construcfi n Valuafion o#Project(excludin tand) $ � �. (, 7 <br /> --•-�----r� � • -- --- <br /> /aPPLICANT ACKNO LEDGENlENT: <br /> i . Agrees to provide alI information required or requested by ihe Building DepartmenC; <br /> � • CeR;fies that the nformatlon suppliec! is tn�e �nci correct to the best of his/her knowledge. Th� appliCanC recognlzes that they <br /> ` are soiely respon,ible for submitting a complete application being awarg that upon failure to do so, the staff has no alternative <br /> but to reject it unt I it is co��pfete; <br /> • Same or all of th in#ormafion thaf you are aSked to pfOVide 011 thls appliCation is classified by State law as either private or <br /> confidential. Priv to data is information which generally cannot be given to the publiC bu� can be gi�en to the subject of the <br /> data. Confidenti i data is informatibr whiCh gener�lly C2nnOt be given to either the public or the subject of the data. OUr <br /> purpose and inte ded ��se of th;s informaYlon Is to annually update our records and records of other governmental agencies <br /> re uired b law. I ou refuse to su I the informa#ion,the a licat'or�ma not be issued. <br /> � � g� � ��� � <br /> ApplicanYs Signature: I'� Date: <br /> Last Uptlated: 05�04-2009 � <br />