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,.k..� .,� sr' ,' ",�y� �j �: <br /> fP <br /> �g �i�y► a� Oo�-o�o � �V � <br /> . , <br /> ' � ' ' � ��.. ,:� _ ° <br /> Buiiding Permit ,�ppiica�io� for IVEainter�ance / F�eno�sa�ion <br /> (windows, doors, siding, re-roof, etc.) �� <br /> � <br /> Mailing Address: a <br /> o,� PO Box 66 Permit number: �D//- U�� a <br />� Crystal Bay, MN 55323-0066 Date received: � � 7 / °'' <br /> (O °'�:a� O S! <br /> a � ' ,��, s, � Sfreet Address: Received by: <br />�.,�; �j �;: <br /> �� ;,„�,_ �ti 2750 Kelley Parkway Pian review fee: �! <br /> _. t'� ESH�g'�/ Orono, MN 55356 �; <br />��`! p Total Fee: ��� 7� � <br /> Main: 52-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �,� <br /> This appfication form must be completed in full and all required information must be submitted. � <br /> Incomplete appficatiorts will be returned. (Please print) "' <br /> GENE AL INFORMATION:� 0 � , ��� K <br /> Job Sit Address: � �� <br /> Will thi be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No `` <br /> If yes a special event permit rs required with Police Department and City Council approva/60 days prior to the evenf. Shu(tle bus service wil/be <br /> � <br /> required unless applrcant demonstrates sutficient on-site parking is available. Non-permitted events will not be allowed. r�.����, <br /> : ;�,r;:; <br /> CONTR CTOR/APPLICANT INFORMATION: '` _ <br /> e�; <br /> Name: ��S_T�12 �r=1S�1�.k..c`jp� � <br /> State Li ense# ZD6'3 S Expiration Qate: :;z <br /> " Lead C rtification Number: � � ��� �`�.- � Expiration Date: "➢ <br /> (for rk on homes thaf were consfructed prior to 1978 � <br /> Phone: �6 . �(7 - vv (office) • (cell) ;� <br /> i� <br /> Maifing ddress � S �,J ,�,� � O City: � ZIP: � <br />, Contact erson: �(„�.`�"� Appiicant is: ontrac r Homeowner (Cirde One) � <br />" Email an /or Fax: - <br /> �PROPE TY OWN�FORMATI N: � �+ <br /> Name: �l �t I�� � <br /> ��. <br /> ,, Phone (d y): /2 - -- 1 O c"� ��, <br /> �' Address: <br />�- J City:C7�'�c� ZIP: s �6 � <br /> p ' Email an /or Fax � <br /> :� <br /> PROJE T INFORM,4TION: ,� <br /> Type of P ject: Any earth movement may require =; <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: �g <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Bivd � <br /> �Re-roof, cedar ❑ Restoration ❑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 /> �,. <br /> ❑Window(s) www.minnehahacreek.orq i=� <br /> Overal! Pr ject Description: — Lc�'� �+ <br /> Estirriated Construction Valuation of Project (excfuciing land) $ � ��J ,— f'� <br /> �:. <br /> � <br /> APPLICA T A�KNOWLEDGEMENT: <br /> � <br /> • Agr es to provide all information required or requested by the Building Department; � <br /> • Ce ifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they �;; <br /> are olely responsibfe for submitfing a complete appfication being aware that upon failure to do so, the staff has no alternafive `� <br /> but roject it until it is complete; � <br /> • So e or all of the information that you are asked to provide on this application is ciassified by State law as either private or <br /> con dential. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the <br /> data Confidenfial da:a is information which generally cannot be given to either the pubiic or the subject of the data. Our <br /> purp se and intended use of this information is to annualty update our records and records of other governmental agencies <br /> re u red b law. If vou refuse p e infor ation,the a lication mav not be issued. <br /> A ficanYs i nature: o. � <br /> PP 9 Qat.. �Z— Z5— '� !'� <br /> � <br /> Last Updated: 8-09-2011 � <br /> a� <br /> : .., .�� , .,.. .�+ <br />