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��—� l CAC��P'1 � ��'i�Y��� i �t �c�LtS� . ; <br /> � � �� 't of O ro n o a �uc�-t� c�-� ��S �- <br /> �-�-�� l�c r rn i 1 2��1-- c���� ,Y-, � / t g l i � <br /> il in P rmi A licafon for Maintenance / Renovation <br /> Bu d g e t pp <br /> (windows, doors, siding, re-roof, etc.) �k <br /> Mailing Address: � � <br /> �,0,�. PO Box 66 Permit number. ��V � — '�C��y � <br /> Crystal Bay, MN 55323-0066 Date received: � <br /> O a' � O Received by: {� <br /> ,� � �y� << �, Street Address: °Y <br /> �',�, t �'�� Gti 2750 Kelley Parkway Plan review fee: ' <br /> t'�kEs J� Orono, MN 55356 <br /> — Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �t: <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please prinf) � <br /> GENERAL INFORMATION: �� <br /> Job Site Address: � � �V / "` �'�y �;� <br /> Will this be a Parade of Homes, emodelers Showcase Home or other Display Home? ❑ Yes �-Wo ;�� <br /> /f yes, a specia/event permit is required with Po/ice Deparfinent and City Council approva/60 days prior to the event. Shuttle bu service wil/be '� <br /> required unless applicant demonstrates sufficienf on-site parking is available. Non-permitted events will not be allowed. �;� <br /> CONTRACTOR/APPLICANT INFORMATION: *� <br /> �._ . � <br /> � Name: � —�� � I � �. .-,�/�c: � ,� <br /> � State License# � ��6��� Expiration Date: �'. <br /> � �� <br />;�, Lead Certification Number: Expiration Date: ;; <br /> ,�: <br /> �- (for work on homes thaf were constructed prior to 1978 <br /> � Phone: 75�. —S�,/'cr_ ���C� (office) �'�a - ��� ��� (cell) � <br /> ` Mailing Address: ��3 I�✓ `1�S '.0 S i. ,$� /"7C City:l�����.��,r ZIP: y�"�3 �� � <br /> Contact Person: ���o `,.� Applicant is: Contractor Homeowner (Circle One) � <br /> �3�-��'' � <br /> Email and/or Fax: ��ju/S�C,�L(�oh„Q G,-„�,'� ,C�%>, ;� <br /> � <br /> PROPERTY OWNER INFORMATION: � <br />��°:: Name: �it/��0�:� /����-r <br /> �� Phone (day): � <br /> � <br /> Address: s�y ��,.,e City: ZIP: � <br /> Email and/or Fax ';� <br /> � <br /> PROJECT INFORMATION: �� <br /> � Type of Project: Any earth movement may require ;� <br /> MCWD review&permits: `� <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) � <br /> ❑ Re-roof, asphalt ❑ Repair torm Damage 18202 Minnetonka Blvd � <br /> Deephaven, MN 55391 `� <br /> e-roof, cedar estoration ❑Water Damage ';�� <br /> � Phone: 952-471-0590 � <br /> � ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> �`' ❑Window(s) www.minnehahacreek.orq ' <br /> � Overall Project Description: �.�,�`yr �,� ,.—� "" '�� t'. <br />, i 9 <br />�'i Estimated Construction Valuation of Project(excluding land) $ � ''��~ <br /> � � f�.. x; <br /> APPLICANT ACKNOWLEDGEMENT: ��<< � �". �r � <br /> ' :;E <br /> �"' • Agrees to provide all information required or requested by the Building Department; <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 application being aware that upon failure to do so, the staff has no alternative � <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 /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our °'y <br /> purpose and intended use of this information is tq,.an ally update our records and records of other governmental agencies `'`� <br /> re uired b law. If ou refuse to sli he information,the lication ma not be issued. <br /> /� � <br /> ; <br /> � <br /> Applicant's Signature: _ Date: � <br /> Last Updated: OS-09-2011 = <br />