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JUL-13 c015 11:44 FROM:TREBILFOUNDATION SYS 3205938720 TO:19522494616 P.2/3 <br /> City of 4ro.no <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) 'l <br /> f�O Mailing Address, Permit number: <br /> 0 Box 66 <br /> Crystal Bay, MN 55323.00681 r / Date received: —! — <br /> Street Addre8s= �!'I( Il�I Received by: <br /> 2750 Kelley Parkway `l Plan review fee: <br /> Orono, MN 55856 p <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952.249.4616 www.0.oMno.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Plosse print) <br /> GENERAL INFORMATION: <br /> Job Site Address: . <br /> Oil this be a Parade of Homes,Remodelers Showcase Nome or other Display Nome? U Yes ^0 <br /> /lyes,a spedal event permit is required with Police Department and City Counell approval 60 days prior to the event. Shutthr bus service w1N be <br /> required unless applicant demonstrates suffl6lent on sft parking Is available. Non-permitted events will not be Allowed. <br /> CONTRACTOR/APPLICANT INFORMAT ON. <br /> Name: <br /> State License# ExpirationDate: t (e <br /> Lead Certification Num er: Wr+101692i". '-f Expiration Date: <br /> (for work on homes that wete cobstfuctffprfur 9b 1978 <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact person: U66 SbApplicant is: n ra Homeowner (circle are) <br /> Email and/or Fax: <br /> PROPERTY O R INFORMATION: <br /> Name: <br /> Phone(day): r I <br /> Address: City: ZIP: <br /> Email and/or Fax .. <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) Q Remodel ❑Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt >Smepair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,caosr ❑Restoration Q Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-OSW <br /> 9-roof,other(specify) ❑Siding r: specify) Fax: 952.471-0882 <br /> ©Window(e) � vvww i ne eek <br /> Overall Proect Descri ion: <br /> Estimated Construction valuation of Project(excludin I d) ate. <br /> APPLICANT ACKNOWLEDGEMENT: <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 /> 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 subjectof the <br /> data. Confidential date is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> r uired by law. If you refuse to sueply the infonnation thd 2pplic2tion ma not be Issued, <br /> t <br /> Applicanfa Signature: Date: <br /> Last Updated, 08-09-2011 <br />