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oily 1fr UfOrt© <br /> Building Permit Application for Maintenance / Replacement / Remodel <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> �O1 V Mailing Address: Permit number: 2o15 Dl O(' <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: a2 f�I I S <br /> Plan review fee: _��.-cj- <br /> Street Address: Received by: <br /> I <br /> A <br /> 2750 Kelley Parkway <br /> `� Orono, MN 55356 �t <br /> �ESHO Total Fee: 7 5 4(.j, 2cifc("- --18-1. il <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted.uw" 8[z i is <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: n' ll I <br /> Job Site Address: 085" We 9&tr Hlus / Li, /a � r'/NC S 3 c�T <br /> yZ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ar No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted even r. ill not be all• ,.. <br /> CONTRACTOR/APPLICANT INFORMATION: ,, a IAA.,' / " <br /> Name: Al eye/ s Soni 5 Co,154,mcAo'. L L i <br /> State License# 13c 6o66/s Expiration Date: 3/3 /Zo/,[ <br /> Lead Certification Number: /'4TZ%_ i/yo / Expiration Date: 7, ? o/6 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (os-/-Z-7/ -'173 9 (office) 611-01r) <br /> Mailing Address: 836,0 4-F-1-o- i aad City: Wood 6,4 ry ZIP: ST'/2 S— <br /> Contact Person: xeh 4- (11.e V-er Applicant is: cCrolitralor Homeowner (Circle One) <br /> Email and/or Fax: 6,1eycrkkiLs1 eaCop„C454- , ne.f <br /> PROPERTY OWNER INFORMATION: <br /> Name: bet/0" S wcev <br /> Phone(day): 4(1-— q/,bcy - $76 g <br /> Address: 1--(77 5 (AA bbec y;/15 gal City: (,i/Giza A.t ZIP: S 539 <br /> Email and/or Fax: devon s w.cerkc me, , corn <br /> PROJECT INFORMATION: Overall project description: / &'*0 et( ba-IA i4 SK ff z' f 3'�,bedcco..,. <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) Remodel 0 Fire Damage MCWD review&permits: <br /> El Re-roof,asphalt Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration 0 Water Damage Deephaven,MN 55391 <br /> 0 Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> 0 Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ 7 r DOO <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 are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> 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 subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su..l the i form.tion,the a..11 .tion ma n'.t be issued. 44/6— <br /> Applicant's Signature: % ,,� .. ` n/ Date: <br /> Owner's Signature: Date: <br />