|
_ n ;T7 a"T,�f�, b"*c � x �.r-* ,y�r+{',�`� -'
<br /> . . I .... '�' . • �. ri : �1
<br /> �1�y �f 0�0�� �: �
<br /> z � ro�
<br /> Building Permit Appli�afio� for IVlaintenance / Renovatio� ��- � �a
<br /> 3
<br /> , . � (windows, cioors, siding, re-roof, etc.) �
<br /> Mailing Address: �7
<br /> ��,0,� PO Box 66 Permit number: ,:� Cl.� 'C 7� •^�
<br /> O �� O
<br /> Crystal Bay, MN 55323-OOo6 Date received: � ��
<br /> � ���^-� �,) StreetAddress: Received by: +� �
<br /> ��'�, �'���Gti/ 2750 Kelley Parkway Plan reviewfee: �'����C2/� �
<br /> t9'kESH�4 Orono, MN 55356
<br /> Total Fee: ,�� �J yf
<br /> Main: 952-249-4600 Fax: 952-249-4616 wwv,�.ci.orono.mn.us Tr��, ,���
<br />`- This appfication form must be completed in full and all required information must be submitted. �,.
<br />``' Incompfete appiications will be returned. (Please print) �
<br /> GENERAL INFORMATION: ' ,��;
<br /> ,;
<br /> Job Site Address: Oo S' C�A l�o i� ZJ , ���d �l � . .�
<br /> Will this be a Parade of Nomes, Remodelers Showcase Home or other Display Home? ❑ Yes No
<br /> !f yes, a specia/event permit is required with Police Departmenf and City Council approva/60 days prior to the evenf. Shuttle bus service wil!be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. `#
<br /> �
<br /> - CONTRACTOR/APPLICANT INFORMATIOI�:
<br /> Name: � t tl �v C-d-n,S� .
<br /> State License # � G Cp��Ci�(� Expirafion Date: 3� Za�3
<br /> Lead Certification Number: Expiration Qate:
<br /> (for work on homes that were constructed prior to 1578
<br /> Phone: (A(�_7 p�j-33,�'1 (office) (cell)
<br /> .�
<br /> Maifin Address: �
<br /> 9 Cit : ZIP: �
<br /> Contact Person: �� y �,.�A�j Appficant is: Contract / Homeowner (Circle One) ��
<br /> Email andlor Fax: �
<br /> >�
<br />� . �
<br />',�' PROPERTY OWNER INFORMATION: �
<br />� ` Narne: �
<br />� '��'IZ,�W� � l Al�� qr
<br /> f
<br />��� Phone(day): � �
<br /> >'
<br /> Address: y ��n� ;
<br /> �oa�7 S t, ��n.,�,,.,d�d 12 D, c�t : z�P:
<br /> :; Email and/or Fax {s�
<br /> �:.:
<br /> b'�
<br />�ri: PROJECT INFORMATIO�E:
<br /> �;:
<br />� Type of Project: i Any earth movement may require �;
<br />� ❑ Door s �Remodel MCWD review&permits: �,
<br />� , � ) ❑ Fire Qamage Minnehaha Creek Watershed District(MCWD) ��
<br />��' ❑ Re-roof, asphalt ❑ Repair ❑ Storm Qamage 18202 Minnetonka Blvd '�`
<br />�
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �
<br />� ' Phone: 952-471-Q590
<br />� '' ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �
<br />� ' www.minnehahacreek.orq u��
<br /> ❑ Window(s) �;
<br /> �;
<br />'`� Overall Rroject Description: �=`
<br />�= n �na�o� ns cJ �h c n�� ��- `,� l -,
<br />� ' Estimated Construction Vafua4ion of Project (excfuding fand) $ / �'
<br /> r.
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department; '�
<br /> 4�u
<br /> • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they , :��
<br /> are sofely responsible for submitting a compfete applicaiion being aware that upon failure to do so, the staff has no alternative i
<br /> but to reject it unti(it is complete;
<br /> • Some or all of the information that you are asked to provide on this applicafion is classified by State !aw as either private or
<br /> confidenfial. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the
<br /> data. Confidenfial data is information which generalfy cannot be given to either the pubiic or the subject of the data. Our
<br /> purpose and intended us this information is to annually update our records and records of other governmental agencies �;��
<br /> re uired b law. If ou r fu to su iv f nformafion.the ao lication ma not be issued. '`�
<br /> Y�
<br /> ApplicanYs Signature: Date:
<br /> ., � Z�. ZoIZ ;x
<br /> �' Last Updated: 08-09-2D11 � �r
<br />�.'°;'
<br />
|