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3 ,��' ` - ��'� �.� s , ' fi' A� -� �. a� �I�y Of O�-o�O �' *�� � � �� Buif�ing Permit App[ication for Mainter�ance / Renovafion ' `�� (windows, doors, siding, re-ro�f, etc.) e : Mailrng Address: _ '' i J�-' � ' �0� PO Box 66 Permitnnumber: ;,_, � , - ;�: Crystal Bay, MN 55323-0066 Qate received: � 2 - ,'; �-; �.�r � �' a '� a, StreetAddress: Receivedby: •(J, �; �_; �� d'��l �J 2750 Kelle Parkwa `i � .��o y Y Pfan review fee: r9kESH�4 Orono, MN 55356 r' � �� Total��Fee: �� "� �: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � �� This application form must be completed in full and all required information must be s bmitted. � - fncompfete appfications will be returned. (Please print) �� GENERAL INFORMATION: � 't+ "'= Job Site Address: � '�f �f � ��' �_y �_. �:. �'� -' Will this be a Parade of Homes, Remodelers Showcase H e or other Display Home? ❑ Yes �' >: ❑ No � /fyes, a specra/event permit is required with Po/ice Department and City Counci/approval 60 days prior to the event. Shuttle bus servrce will be � ��.< required unless applicant demonstrates sufficrent on-site parking rs available. Non-permitted events wil/not be allowed. �j CONTRACTOR!APPLICANT INFORMATION: t �� '` Name: �%,,,, ,/:�� ; f��r�� - �jv, �� � State License # --� ,;'� c- S/ 3 j � - � � Expira�ion Qate: ; s� �y �� Lead Certificafion Number: Expiration Qate: � �k�. (for work on homes thaf were consfructed prior fo 9978 4� � Phone: (office) (cell} � Maifing Address � �S'� �� ;� - �'{-i� �c City: ZIP: � Contact Person: S�c�.T C-c��r Appficant is: Contractor / Homeowner (Circle One) � ��. Email and/or Fax: S��ft�(�' �1�� ; (t�er.� , c'cr,�� -------- . � PROPERTY OWNER INFORMATION: �� . :. q.�� Name: �l'�Vi�( �c�S�� '-- �° ��, Phone(day): YS z " �-I `7 ( - � yC �( ° ��a Address: ��° r, __c' Y�L �l ,:l'�� • c,�{ City: (��r-�o ZIP: Email and/or Fax ��: PR�JECT INFORMATIOI�: � , :: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑ rire Qamage MCWD review&permits: � Minnehaha Creek Watershed District(MCWD) ❑ Re-roo f, asp ha lt ❑ Repair ❑ Storm Qamage 18202 Minnetonka Blvd sF ' ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ' ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �; ,�Window(�a'j www.minnehahacreek.orq ;�� �� Overall Pro'ect Descri tion: �` - � � �a , P ' _ , - T`-=--T--. -.i—{�.�,–Cr–t-E.r.�� .- , ;�� i�.� .�,):k. C.i. i��`o a. _Estimated Construction Vafuation of Project (excluding land) �� , �'� � �.�� '�� . ,:; APPLICANT ACKNOWLEDGEMENT: ��" �{; • Agrees to provide all information required or requested by the Building Department; ;� • Cerfifies that the informafion supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they 'r� are solely responsible for submitting a complete applicafion being aware that upon failure to do so, the staff has no alfernative =�' but to reject it until it is complete; �� �� • Some or all of the informafion that you are asked to provide on this application is cfassified by State law as either private or "*`R confideniial. Private dafa is information which generally cannot be given to the pubfic but can be given to the subject of the { data. Confidential data is information which generalfy cannot be given to either the public or the subject of tne data. Our � purpose and intended use of this information is to annually update our records and records of other governmental agencies � "�� re uired b law. If ou refuse t the information,th�ao lication ma not be issued. � �� A IicanYs Si nature: ��.� � �' 7 ��- ' PP 9 �''�f-_ �� Date: �� j�<=-; z---� � �-- --� ,� Last Updated: 08-09-2011 ;;� �.� u4r