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T�+esda;+,.luly 19,2011 4:09 PM Coty Construction 952-934-0099 p.02 <br /> Gity of Clrono <br /> Building PQrmit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> /��O;�Y� Malling Address: Parmlt number. �dl l�D�P $ <br /> O,� ,�� PO Box 86 <br /> � C r y s m l 8ay.M N 5 5 3 2 3-fl 0 6 a o�r e c e�v�a: 7/,�-D // <br /> � �, SheetAddress: Rc'icelved by.• _ � <br /> 2750 Kelley Parkway Plan reviaw fee: <br /> ��� �4,� Orona,MN 58366 aT <br /> `�_�. _:! 7otal Fee: 3(��, �C.J <br /> Main: 96Z-249��iUU Fax: 962-249-4616 www.ci,orvno.rnn.uq <br /> This application form must be completed in full and all r�quired intormaGon must be s bmtttod, <br /> Incomplete appllcativns will 6e ret�rned. (Pl��print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 4448 N.shore D�ive <br /> Will this be a Pa�ade of Homos, Remodelsrs Showrcase Home or other Diyplay Home? ❑Yo� � Nd <br /> I!yes,a speciel svont peni�lt Is requ,red w1U�P�ce Dapartmont anr/Cily Cau�►u7 npprcvel6D dr�ys prinr ta fhe oucnf ShutU�l DUS so�vfce wiU 1� <br /> requir$d un/ea�eppUcanf demuneVritrs suflicieiU wl•slfe pa�lcfng�s aVallAble. No�permlffed events uJiU not be aUlowed. <br /> CON7RACTOR 1 APPLICANT INF�RMA710N: <br /> Name: Coty Construction and Re'modeDhg <br /> State Licens�# BC-20431519 Expiraiion Oate: p�131/201Z <br /> f�tlone: (992)934-7800 (offioe (612 599-8387 ceIIL <br /> M�iling Address; �/�d��Qn Ay� CI . Minnetonka zlp; a�sa� <br /> Contact Person: Pa Co _ Applicent Is:�Contractor / HomQowner (Clrcla 4ne) <br /> Email drydlo�I'ax; er, tna.cotvconstruclion.com �9 26 1934-0099 <br /> pROPERTY OWNER INFORMATlON: <br /> Name: Murlel Senn . <br /> Phone(d�y): �952 d) 72�{486 .— Ci�,• Orono ZIP: 55364 <br /> AddrAss: 4448 N Shvre Drive <br /> Email and/or Fax — <br /> PROJECT INFORMA710N: , <br /> Type of ProJect' My eerth movement may requlre <br /> ' twCWD�evlow&Permil� <br /> ❑Dooris) �Remodc� �Water Damaga <br /> Mlnnehaha Crook Walershod DislriCt(MCWDj <br /> ❑Winduw(s) Q(tepait ❑5torrn Damage 18202 Mfnnetanka Blvd <br /> Deaphavrn,MN �91 <br /> ❑Sidin� �Rsstorripon []Olhar.(speCify) Phone: U52-471-0680 <br /> F�x: 8�2�471-0682 <br /> �Re-roof []Fire Oamago w,ww.minnAhahacreek,o�4 <br /> Oderall P�ojoct De�cription: — <br /> Estimatod Construction Valuation of P�oject(excludiog land) $16,609.00 , _ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Agrees to provlde all 1nPormaUan requirod or requested by the Butlding Qepartmanl; <br /> . Ce�tlfl@e that tfle Iniomuation SUppllod Is ttua and crnrecl to th�best of hi�lhor knowlodg�. Ths appllcant recnenlzes Ihat thQy <br /> ars solely responsible for submf�ing a comp�e�e appll�lion be�ri�awere that upon tatlure�o do so,the st�ft has no�Itemative <br /> but to rojod i�untll it is complet�; <br /> • SOf08 0�ell O(1h0 infGm18li0(1 117ai you 8fC SsKed to provida on tttis 8ppliceliort ia claeaiPfad by�tate law�s eithet pflv�le o� <br /> confldenHel. Private dat�► f�Informatlon whioltg�re0y cannol b Iven to the puhll� but can be glven to lhe suhjoct of lhe <br /> da[2. ContiClentlal date Is informatJon whtbh goners y cannot givon ta efther tho p��blic or the subject of the �alo. Our <br /> purpasa and inldndad use o1 U11s frdfo'RnaUan ie to uall ate aur rocorde end recottis of other flovemrnentFil ctc�encres <br /> ro uired by law. !f You refuse to S�pply the Infor lication ma not be tssuad. <br /> ,� � <br /> Appllcant's 5lgnature: _ uote: o7H912o11 _ <br /> / <br /> �asc uaaBt�: os-oa-aoos � ,, <br />