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�«y �E VIVIIV <br /> Building Permit Application for Maintenance/ Repiacement/ Remodel <br /> 49.r�.. �•93E'��i✓v�"`�F�, .,���if�� �n�7� �9 � � �.�,� �: �n ��r �r^`��� <br /> � ��t � �,�, °�"2'"� 'd�-fP-:.rr9G�.� �`c�4.. .�- �a'al1 � � ��.+�r J mJ��3&`�!� l�ra��°P.1b��'o.:��:, <br /> O Mailing Aaldress: permit number: p7��S�O � <br /> � �TO PO Box 68 _ <br /> Crysta{Bay,MN 55323-0066 Date received: "- � <br /> 1 <br /> � j Sfreet Address: Received by: <br /> y � 2750 Kelley Parkway Plan review f � <br /> � � Or�no,MN 55356 �� �� <br /> �k�SH�'�� Tolal Fee: <br /> Main: 952-249-4600 Fax: 952-249-46'k6 v,rww.ci.orono.mn.us <br /> This application form must be completed in full anci all required information must be submitted. <br /> Incomplete applicatfons will be retumed. (Please prinr) <br /> GEN�RAL ENFORMATION: ` <br /> Job Slte Address: ��_ g�G.�i L(WLY�[J� {�-[��. <br /> WiA this be a Parade of Homes,Remodelers Sh�ase Honte or other Display Home? Yes �No <br /> !f yes,a spec�al event permit is required with Potice Department and City Council approva160 days prior io Ghe event. Shutlle bus servrce will be <br /> required unfess applrcant demonstrates suHicient on-sRe parlcing is availabfe. Non-pem�itted events wi11 not be a(lowed. <br /> CONTRACTORlAPPLICANT INFORMA170N: <br /> Name: ���-..� 2 [J C <br /> State License# f����c��� s,s __ Expiration Date: '�� �� <br /> Lead Certification Number n�,.i-j�2 F;y 2► Expiration Date: ��1 <br /> (for work an homes that were corrshucted prior to i978 <br /> Phone: (ce(I) �j�-��-- ��1��° (office} ��,'���- �j�(�C( �-. <br /> Maiiing Address: � Ci 2�.- 2Ln-N,. ��t� /�_ C��'� �l,P�(.1J ic�iYtCh�'�_ ��i ) � �' <br /> Contact Person: �.�� �,��(r��f Applicant is: Contractor / omeowner (Cirde One) <br /> Email andlor Fax: �.i�I-x;��r�r3Fc— r—u�r,P sn�a [ r�'rn lG�I -(n��"�I(�{�J <br /> —� . <br /> PROPERTY OWNER INFORMATION: <br /> Name: 1�Y1 G+-irl � j �--i1J l 0 1� y <br /> Phone(day}: �l �=�'�S-- Q��l l <br /> Address: � p��y�y� � City: 21P: <br /> Email andlar Fax: <br /> PROJECT fNFORMQTION: Overall ro" ct descri tian: � � �� <br /> 7ype of Project• Any earth mavement may also require <br /> ❑Door(s) . ❑Remodel ❑ Fire Damage MCWD revlew&permits: <br /> ,�Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Waiershed District(MCWD) <br /> 18202 Minnetonka B[vd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other: (specify) Phone: 952-479-0590 <br /> Fax: 952-4'71-0682 <br /> ❑Wirxiow(s) •r�;vvr.minnehahacreek.orq <br /> Estimated Constructlon Valuafion of Project(excluding land) $ / '7_ �[�[3_ �'a <br /> APPLICANT ACKNOVI�LEDGEMENT: <br /> • Agrees to provide ali information required 4r requesied by the Bui{ding Departrnent; <br /> • Cert�es that the information supplied is true and correct to the best of hislher knowlec�e. The applicant recognizes that they are <br /> solely responsible for submitting a complete applic�atron being aware that upon failure to do so,Ihe staff has no alkernative but to <br /> reject it until it is complete; <br /> • Some or a11 of the informaiion that you are aske� io provide on this appfication is ctassiRed by State law as either pr�vate or <br /> oonfidenlial. Private data is information which generally cannol be given to the public but can be given to the subject of the data. <br /> Confident�al data is information which generally cannot be given to either the public or the subjed of ihe cSata. Our purpose and <br /> intended use of this information is to armua9y update our records and records of other govemmental agencies required by law. If <br /> refuse to su I the infarmation,the a Ifcati�n ma not be issued. <br /> Applicant's Signature: ,�.f 1r7 �Z.�� ��� � � �� �� <br /> OwnePs Signature: fl�� <br /> Z'd E616-££9-699 sn y s;oo�{ �EZ�06 96 601nf <br />