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�>� >� ti�. <br /> _r <br /> �i��/ O� ��'C�i�Q r: k ; <br /> � � ' <br /> � � . <br /> ` Building Permit Appi�ca�ion for IV�ainter�ance / Renovatio� �� <br /> (windows, doors, siding, re-roof, etc.) <br /> MaifrngAddress: Permitnumber. p�� — �y <br /> /Ov^�.,0,�-O PO Box 66 �, <br /> � Crystal Bay, MN 55323-0066 Date received: <br /> �� � ' ,�.,��,�,� � Street Address: Received by: � <br /> �'"�n � ;'�' ti 2750 Kelle Parkwa � �� � <br /> � o Y Y Pfan�review fee: � <br /> \L9kEs�4`� Orono, MN 55356 <br /> � Total Fee: p���f, L J� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be complefed in fuil and all required information must be submitted. � <br /> Incompfete appiications will be returned. (Please print) � <br /> GENERAL INFORMATION: � ��� <br /> Job Site Address: .�C��(� `j'�{',R�� '�.�;Y <br /> Will this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑ Yes o <br /> lf yes, a specra!event permit is required with Police Depariment and City Council approval 60 days prior to the event. Shutt/e bus service wil!be <br /> required unless applrcant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> 5$ <br /> C�lVTRACTOR/APPLI ANT INFO M TION: � <br /> Name: � � , (�,� <br /> State License # '� �9� � (�,�� Expiration Date: 3- ?� - �y � <br /> Lead Certification Number: Expiration Date: � <br /> (for work on f�omes that were constructed prior fo 1978 � <br /> Phone: , _S• -- _ l�`,3 (office) (cell) �u <br /> Maifing Address: l ��f� � City: � 1�ti� 11 ZIP: �S�/y2 �� <br /> Contact Person: �� ,,.J Appficant is: ontractor / Homeowner (Circfe One) � <br /> Cmail and/or Fax: � � �, �� --- <br /> PROPERTY OWNER INFORMATION: <br /> Name: S a-� �b e� <br /> � <br /> Phone(day): (012 _ �.,q;L - ��� �`j ' �. <br /> Address: �,@�,f` J 1�4 1�.'� l�� City: ZIP� <br /> Email and/or Fax '��� <br /> � <br /> PROJECT INFORMATIOI�: � <br /> Type of Project: Any earth movement nzay require � `s� <br /> ❑ Door(s) ❑ Remodel MCWD review&permits: � <br /> ❑ Fire Damage Minnehaha Creek Watershed District(MCWD} � <br /> �.Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd '�. <br /> F, <br /> ❑ Re-roof, cedar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 ;� <br /> ❑ Re-roof, other s eci Phone: 952-471-0590 � <br /> ( p fy) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 � <br /> ❑Window(s) www.minnehahacreek.orq <br /> � <br /> �. <br /> Overall Project Description: � � _ � <br /> Esfimated Construction Valuati�n of roject (exciuding fand) $ /,� . �l �J � <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: ;� <br /> �� <br /> • Agrees to provide all information required or requested by the Building Department; �, <br /> � <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they � <br /> are solely responsible for submitting a complete applicafion being aware that upon failure to do so, the staff has no alfernative � <br /> but to reject it until it is complete; �� <br /> ;� <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or � <br /> confideniial. Private data is information which generally cannot be given to the pub(ic but can be given to the subject of the I �, <br /> data. Confidential data is information which generaliy cannot be given to either the public or the subject of tne data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies ! � <br /> re uired b law. If ou refuse to su I the informafion,the a lication ma not be issued. ;� <br /> // ;`�4 <br /> ApplicanYs Signature: -?/`�j� � Date: � ^� ' 13 :y, <br /> Last Updated: OS-Q9-2011 <br /> ; <br /> . '.� <br />