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08/23/2911 14:05 9528885554 PAGE e1 <br /> - � � �' City of arono <br /> Building Permit Appl'r�ation fo� Internal Work <br /> (windows, doors, sidin , re�roof, etc.y <br /> Mall;ng Addresa: Permit number: <br /> �0.� PO Box 66 _... <br /> Q � Crystal6ay, MN 55323-0066 Date received: <br /> � a Sin9ef Addr�ess: Reoeived by: <br /> �' 2750 Kelley Parkway Plan revlewfee: <br /> !`V�,� ��' Orono,MN 55356 <br /> Maln: 852-249-4800 Fax; 952-248-4616 n ,us Tots�Feo_ � <br /> This applicatlon form must be completed in fuli and all r�quired information must be submitted. <br /> Incomplete appiicafiions wili be returned. (Piease pnn� <br /> GENERAL IN�ORMATION; � <br /> Job Site Address: � � n <br /> Will thls b�a Parade vf Homes�Remodelers Showcase Hom r other Display Hcme4 Yes No � <br /> li yes,a spacial e�renf permit is requirad with pollce Depertment and Ci�Cour�cll opprove!60 a�eys pnbr tc fhe avenf. ShutNe bus servlce will be <br /> required unless appflcanf dernonsfrales suff'roient on�sna pa,kinq is avalleb/e. Non-permKlad aveMs wiAnol be efJowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �qK,��l��. S�,E �� �x��..__ <br /> Stabe License# ��� G6 Expiration Date: 3 31-1 a,. <br /> Lead Certi�ication Number� (�- �gS p�_� Expiratlon pate: b as— 1 S <br /> (for work on homes tbat were consNuCted pdor M 1978 - ' <br /> Phone: S'-5'S.T`[� (officej -�a S-8S'G (cell) <br /> Malling Address: City: ZIP: s5 �a <br /> Conbct Person: s-�V e Appli nt is: Contracto omeovmer �cikiR on.� <br /> Emeil andlor Fax: Q�,,,�,�,,n Q Lr�R�Nc . w1 ei- <br /> PROPERTY OWNER INFORMATION: <br /> Name; S-1r�.J 2 5 cL M�e�C. <br /> Phone(day): a, ,r 8.3,` - -' _, <br /> Address: City: ZIP: <br /> Ernail and/or Fax ' • <br /> PROJECT INFORMATION; � Se' �'�Y��, _ ' ��' +'C�� � ��' � �Q, <br /> Type of Project: Any ea mrnreme�t may requlre <br /> ❑Door(s) ❑ Ramodel ❑Water Damage MC��view 8 permlts; <br /> Minnehaha Creek Watershed District(MCWOj <br /> ❑Wlndow(s) ❑Repair ❑Storm Damage 18202 Mlnnetonka Blvd <br /> ❑5fding ❑Restoration ❑Other.(speclfy� ph nee 852�T1-0590 <br /> � Re-ro�f ❑ �ire Damage Fax: 952-471-0682 <br /> w_ww,minnehahacreek,om <br /> Overall ProjeCt Descrlption: �p�r p.�� .-r�p,o� N� •+. �,rc�.�, <br /> Estimated Construction Vatuation of project(excluding Iand) 3 l l, qbo <br /> aPPLICANT acKNOWLED�EMENT: <br /> • Agrees to provide all information required or requested by the Building pepartment; <br /> • Certfies that tl7e informatlon supplied is true and oorrect to the best of hislt�er knowledge. The applicaM recognizes that they <br /> are solely responsible for submitting a complete appUcation being aware that upon failure to do so,the�taff has no altarnative <br /> but to reject it untll it ia complete: <br /> • Some or all of the infomtation that you are asked to pro�ide on this application Is classified by State lew es either private or <br /> confider�tiel. Prlvace data is infonnatlon which generally eannot be glven to the public but can be given to the subject of the <br /> data. Confidential date is iniormatlon whioh generally cannot be given to eRher the public or the subJeot of the data. Our <br /> purpose and Intended use of this Informadon Is to annually update our �rds and reeords af other goverrimental agencies <br /> re uired b law. If au refuse I the ir�formation the a (lcetion ma not e issued. <br /> ApplicanYs Signature: �� Datv: r�'"�!1 f <br /> Last Updated: 03-01-2011 <br />