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��y u� vr u��v � �uilding Permit Appiication for Maintenance / Replacement / Remodel �(i.e. windows, door�, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) �O A,O MailiPO Bo�r66 � Permit number: � �J' � �V / Crystal Bay, MN 55323-0066 Date received: �// / �, ,� , Street Address: Received by: � ti � 2750 Kelley Parkway Plan review fee: F� �� Orono, MN 55356 �Kf ti HO� �.//" '�� 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 mus be submitted. Incomplete applications will be returned. (Please printJ GENERAL INFORMATION: Job Site Address: �1' �p . 55 3�j I Will this be a Parade of Homes, Remodelers Showca Home or other isplay Home? Yes No /f yes,a special event permit is�equired with Police Department and City Council approva/60 days prior to the event Shutt/e bus serviae will be required unless applicarn demonsirates sufflcient on-site parking is available. Non permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATI N: Name: C'q,(SO I` �Cd� 1-.1-"'G State License# Expiration Date: 3 3 � I Lead Certification Number. �} �. � �5 � �� - � Expiration Date: 2,,, (for work on homes fhat were constructed prior to 97 Phone: (cell) b (office) S vh�, Mailing Address: �,�, � City: �K� Q ZIP: Contact Person: � Applicant is: on rac or / Homeowner �a�cMeo�� Email and/or Fax: v �G �Y►'�, PROPERTY OWNER INFORMATION: Name: - _��R�G� g'D L-�� Phone(day): �S2 -�-�-16 - D(�-7� Address: �00, C�G Vt r�Y T 4 �i� (�� C�tY� w �y Z/�-T�} ZI P: �5 3 Gl � Emait and/or Fax: ��b�I�,r1vS v h.^S � • ��^ PROJECT INFORMATION: Overall ro'ect descri tion: Type of Project: Any earth movement may also require �Door(s) ❑ Remodet ❑ Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 ❑ Re-roof,other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 �Window(s) www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ C APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot given to either the public or the subject of the data. Our purpose and intended use of this information is to annually up re ds and records of other governmental agencies required by law. If ou refuse to su I the information the a lica no issued. Applicant's Signature: �Date: ` �� i � Owner's Signature: � •�1 G,v Date: S �� (�J .