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09l1512017 16:12 Dercon Construction �A�f)7639513019 P.0011001 <br /> City of Orano <br /> ri-�---�j"'-� <br /> Buildfng Permit Appticatien for Maintenance/ Replacemertt/Remodel—'�_F:�esrj�d;en"�i:�l��'MfL:Y <br /> ; (i.e_windows, doors, siding, re-roaf, etc.—NO STRUC'�URA�EXPANSION) <br /> ��A} Maili pA�d�z 6s�s: PeRnit numb�r. " � <br /> �vQ — <br /> Crystal Say.MN 55323-0066 Qat�receiv�d: 'I 7 <br /> StreetAddress: Received by: <br /> �- ` 2750 Keliey Parkway Plan review fee: <br /> `�{yk�s�a��,� �rono,MN 55358 <br /> Tataf Fee: O�(/g/ <br /> Main: 952-?_A�9-4600 ��= 952-249-4616 www,ci,orono,mn,us <br /> This appliCation form mUst be CQmpleted in fUll and all required information must be submiited. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: f� i <br /> Job�ite Address. � � Y� � � �\�t�,1,� <br /> WI[I this he a Parade of Homes,Remodelers$ho case Hame or other Dlsplay Home7 Yes No <br /> lf yes,a specis!event permit is requi�d wdh Polrce Department and Cily Counci!approval 60 d$ys prior to tha event Shuttle bus servrce wi!!be <br /> �equired unJess applicarrt demonstraf�s suJfica�ent on�sita paricing is available. Non-parmitted events will nvt be ellowed. <br /> CONTRACTaR/AP LICANT INFQRMATION: <br /> Nam�: �L'�(,Oc1� C,��1.��'WC�'(��/1 ��C�.� � 4�G , <br /> State�icense# (3�j��,fi�l� _ Expiration oate: C�3��1 � i G <br /> Lead Certification Number. � "��j'3� Expiration Date: � � �- I <br /> (for work on homes�at were cnnstruated prior to i978 <br /> Phone_ (cell) ��L,�Z�T(�-(p Q(�(� (office) <br /> Mailing Address: � �"j O ` �, �}W City: �, p�,� ZI P: �j�jD�-� <br /> Contact;Person: ���(`j � Uv-�� Applicant is: on or / Homeowner (Grcle One) <br /> Email and/or Fax: �•����c�@�e,,rcpv�•(,Ov� <br /> PR4PERTY OWNER INFQRMATIO�J. <br /> Name: �..�'��. W'�\��1 <br /> Phone(day): '�j�� -- �j�^ ��-`► <br /> Address: '�t`d0 '(��c�, ,v�o� C�•�v~c. ���� Lo�no�L�rn.e. zfw: ��,��(, <br /> Email and/or Fax: 0��� (Gl�,\r,.�iL`�a� �Covv� <br /> PROJEGT INFORMATION: �verall ro"ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ❑Remodel 0 Fire Damage <br /> MCWD revi�w 8�permits: <br /> �Re-roof,asphalt ❑Repalr �Storm Pamags ��nnehaha Creek Watershed DiStrSct(MCWD) <br /> 95320 Minnetbnk9 Blvd <br /> ❑Re-roaf,cedar ❑Restoration ❑Water Damsge Minnetonka,MN 55345 <br /> ❑Re-raof,other(specif� ❑Siding �Other:(spec�fy) Phone: 952-a.71-0590 <br /> Fa� 952-47T-06$2 <br /> []Window(sy www,mlrtrLet�aha�Laek"ora <br /> Estimated Constwuction Valuatlon of Project(exaluding tand) $ 1C1��{7 <br /> APP�,IC,A,NT,AG�C�IOWLEDCyEMENT: <br /> • fLgress to provide all informatian required or r�quested by the Building Department; <br /> . Cert�es that ihe inforrnatlon suppliad is true and correct to the best of his/her knowledge. The applicant recagnizes that they are <br /> so�ely responsible for submitting a complete application b�ing aware mat upon failure to do so,the staff has rto altemative but to <br /> rej�ct it unti[it is Complete; <br /> • Some or all of th� information that yau are asked to provide on thls appiication is classified by State law as either private or <br /> cortfidential. Prlvate data is ir�format�on which generally cannot be given to the publfc but can be given to the subject of the d�te. <br /> Confidential data is information wl�ich g�nerally cannat be given to either the publlc or the subject of the data. Our purposa and <br /> intended use of this informatian is to annually update our records and records of other govemmental agencies required by law. If <br /> ou ratuse to su I the information,tiie a licatlon ma not be issued. <br /> Applicant's Signature: U�'�� `�� ' Date: � " ���� � <br /> Owner's Signature: Date: <br /> Last Updated'.lanuary 2016 <br />