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w <br /> Cit of 71� Z� <br /> y arono <br /> Buildtng Permit App(Ication for Maintenance/ R�placerrtent/Remodel - � <br /> (i.e. windows, daors, siding, re-roof, etc. - NO STRUCTlJRA� EXPANSIQN) � <br /> Mailing Addrass.' ` " r' "� ^ J <br /> �!a1�T� �e►mr�, ���f�►� ����? <br /> Po sox 66 `�1��� � �` � <br /> C►ystal Bay. MN 55323-OOB6 I�ate xe�tved � `r.��, !, <br /> „ , - <br /> .�. StreefAddress: Re�a�#��r '.,,, <br /> '�F � 275Q Kelley Parkway a� ` '` ', � <br /> �S��S�Q�.E�' Orono,tV�N 55356 �� ��'�� , <br /> � <br /> TOxa#� . , ^ � <br /> _ Main� 952-2491t640 Fsx: 952,249-4616 w4yw,ci.orQ�,Q mn us . �;� � <br /> This appliCation form must be completed fn full and alf required infiarmation m t b submitted, <br /> lncomptete applic�tions wilf be�turned. (Please print) <br /> GENERAL INF�Ftl1AATlON: y�P�E7�-� , <br /> Job Site Addrsss: I�_�._���-�, L 1� – <br /> Will thfs be a Parade oi Homes, R�emodelerg Showcase Home dr other Display Hame? ❑Yes No <br /> lf yes,a specla/eve�perm�t rs r2t7uired wdh Police D@pertm�nt dnd Cify Cpu»cil epprova160 days pnor to fhe event, Shutt�e bus Service w!!!he <br /> requfr�d unless applicsnt demonsb�tas s�cient on�ite parfcing is availabl�. IVon-permilted evertfs will nof be alloweq, <br /> CON7RACTOR!ApPLICANT 1NFORMA710N: <br /> Name: <br /> St�te L.icense# �xpiration Date: <br /> Lead Certfficafion Nurnber' �xpir�tion Qate� <br /> (for work on homes#hat were construc#�d prlor ta 7978 <br /> Phone: (cell) �4���� <br /> '' Mailing Address: City: ��p: <br /> Contact Persan: plicant is: Contractor / pmeowne <br /> tCIr410 One) <br /> Em�il and/pr Fax: <br /> i <br /> PRQPE�'tTY OWNER INFORMA,TION: <br /> Name. LD�� � e ., d � �� <br /> ' Phone(day): (� � <br /> I; --���Q��. ���� <br /> Address: C��; {�' S� <br /> Emaif and/or F'ax; _ � <br /> PRQJ�CT lNF�RMA"CION: Overail roject descri tion� 5' � �, �, <br /> II �'ype of ProjeGt' ' !'y9 <br /> Any earih movement m y also requlre <br /> � <br /> ❑�oor(s) �Remod@I �]Fira Damage MCWp reveew&p�rmits: <br /> ❑ Re-roof,asphaEt 0 Repair ❑$�orm DBmaga Minnehaha Creek Watershed District(MGWp) <br /> ' ❑Re�-roof, cedar Restoration 't5320 Minnetonka Blvd <br /> P � ❑Water Damage Minnetonk�,MN 55345 <br /> , ❑Re-roof,other(sp�cty) [„]Siding �p�,��;�sp��;�� Phona: 952-1t71-0590 <br /> Fax: 95�-a71-0662 <br /> I .,,. ❑Window(s) — inne ereek <br /> � �stimated Const�uCtion Valuation of Projact(excluding f�nd) $ � ... �p <br /> I APPLlCqNT ACKNOWLEDGEM�NT: <br /> ! � Agrees to provide alf informstion required or requested by the BuiMding Department; � <br /> `� Certifies that ihe information supplied is true and correct to the best of his/her knbwle�dge. 'fhe applicant recognizes th�t they are <br /> • sofety responsible fnr submitti�g a complete application being awsre that upon fallure to do so, the staff has no alternativ� but to <br /> � reject i#unti!It is complete; <br /> �F- • Some ar al! of the intorrnation that you are asked to provide on this applicafion is ciassified by State law gs either pnvate or <br /> confidential. Pr€vats data Is information which generally cannot be given to�hg publiC but can be given to the subject of tha data. <br /> , Confidential data is informa�ion which generaUy cannot be gfven to eiiher the public or the subject af the dat�, Our purpose and <br /> jf intended use of this information is to annually update our r�cords and records of other govemm�ntal agencios sequir�ed by law, tf <br /> ou r�fuse to su I the in ation,the a lication ma noi be issued. <br /> � <br /> IAppllcanYs Slgnature: ��"�'""'""�' � <br /> � Date' �� <br /> 'IOwrzer' 9 . , _. , �._ <br /> , s Signatura: Date: ' <br /> �I.ast Updeted:January�1g <br /> i <br /> ! <br /> i � <br />