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- City of O�ono <br /> ' � Buiiding Permit Application for lnternal Work <br /> ' �win�dows� doors, sidin , re-roof etc.) <br /> O MalJing Addr�ss: p�rmft number. v�0//—O/�.D � <br /> Og .�� PO Box 68 <br /> Crystal Bay,MN 55323-0066 Date te�eived: /O ��v—�� <br /> .�' St►�eet Add�ss: Received by: <br /> �� $o� 2750 Kelley Parkway Plan review fee_ <br /> � Orona,RAId 55358 <br /> Totel Fee: <br /> Main: 952-248-4800 Pax: 952 249-4618 �rww.d.orono.mn.us J��' � <br /> This application form rnust be completed in full and all required information must be submitted. �, (� <br /> Incomplet�applica�ong will be retumed. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Addr+esg: y a�5 cv s�•o�,e. �r; $. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,s apedal�voent permff/s requlied w!ri►Po/k:e Oepertment end C�"ty Councll epp�ova/80 daya prfa�!014�e svenL 3Huttle bus s�nrtrs wNl be <br /> �eqW►ed unless applrc��t demonetrades auffictent on-s/t�parking is evaUable. NwrFermlited events wtAltotbe eNawsd <br /> CONTRACT�R I APPLICANT INFORMATION: <br /> Name: Renewal By Andersen <br /> State License# 1920 County Road "C" West Expiretion Date: <br /> Phone: Roseville, N1N 55113 (cell) <br /> Mailing Address: CitY: ZIp: <br /> Corrtact Person: Licens�#20130983 ,t is: Contractor / Hom�nmer �ci�rae o�e� <br /> Emaii and/or Fax: 651-264-4777 <br /> PRCPERTY OWNER INFORMATION: <br /> IVame: '��cl�ine. �,J�10►.�0 G1� <br /> Phone(day): e1.�y� a —(�u�� <br /> Address: '�` _ C�t • Z!P• <br /> Email and/or Fax <br /> PROJECT IIVFORMATiON: � �'h�� <br /> Type of Projec� s � ' Any earth movement ma�r ev�quire <br /> � �� MCWD revisw 8 permits <br /> j�Door(s) ��`� ❑ Remodel ❑Waier Damage <br /> Minnehaha Creek Watershed Distrid(MCWD) <br /> s) C Repeir ❑Storm bamage 18202 Minnetonka Bivd <br /> ❑Sj��9 ❑ Restoretion O�phaven, MN 55391 <br /> ❑Other. (specify) Phone: 852�71-OS90 <br /> ❑Re-roof ❑ Fire Oamage F�: 952-471-0682 <br /> w�w.minneh�hecre� ora <br /> Overall Pro eet D�c�i tbn: <br /> Estimated Constn,ction Vsluation of Pro eet �xaludin land $ ,p(� <br /> APPLICANT ACKNOWLEDGEMENT: • <br /> • Agrees to pravide all informadon requtred or requeai�by the Building Department; <br /> • Cerf(fiea thal the lnformation supplied is true and oorrect to the best of hiaJher knowledge. The applicant recogniz�s that they <br /> are salely respo�ible for subrnittlrtg a complete application being awere d�at upon fanure to do so, the siaff has no altemative <br /> but ta reject(t until it is ccmplete; <br /> • 3ome or all of the iMormation that you are asked to pro�lde an this applicaiion is dassifled by Stete law as either prlvate or <br /> ooMidential. Prlvate data is i�ormation which generally cannot be Biven ta the public bui can be 8iven to the subjed of ti�e <br /> da�. Cortfidential data is )riformation which generally cannot be given � either the publlc or the subj�ct of the da�. Our <br /> purpose and intended use of this Infoimation is to annually update our recorda end recorda of other gevemmental agencles <br /> ired law. If ou refuse to su 1 the informatlon the a licetiom m �a1 be isaued. <br /> Appli�arrt's Signature: Date: �p�l+ <br /> Las!Updeted: 03-04-2008 <br /> Z 'd 06T9�bL9TS9 3�I11�135 lIWa3d Q '8 S I� SS �G TTOZ 90 ��0 <br />