|
LfILy VI VI VI IV
<br /> Building Permit Application for Maintenance/ Replacement/Remodel — Residential ONLY
<br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION)
<br /> W
<br /> o Mailing Address: Permit number: 00(8p0;36 r
<br /> POBox66
<br /> Crystal Bay, MN 55323 0066 Date received: 3-��v
<br /> Street Address: Received by: Q 2750 Kelley Parkway Plan review fee: o2U1.Orono, MN 55356 vors-Q 036,9
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us T-I t1 /7
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: ,765 '4, ,o j6,/,t)7 JoA®
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ YeserNo
<br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus vice will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: CiJAZ 2) /lair.) aft Lt
<br /> State License# /3(.3F0):57 2) /,g
<br /> Expiration Date: j31/j9
<br /> Lead Certification Number: /097-37/q, -' Expiration Date: 11/01/25'
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) 6'`Z—Zo '/..-67y2._ (office) 95Z- g35' Yr6.7'
<br /> Mailing Address: /5)5 3,,,/j 6`eti i f City: /e)ti,US ZIP: -53-31/1?
<br /> Contact Person: ))/gti ve p-1,/ Applicant is: ontractor+)/ Homeowner (Circle One)
<br /> Email and/or Fax: 2,4, i4.0Az,6e- ,�y,,),6„,..)z,b)f,L�/�?
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ,,//4 4,-'S .241)
<br /> Phone (day): 61Z- 'fid 7 //
<br /> iO
<br /> Address: 1_;i14 O O>,i4 7,,i4/ City: 4f7 4A2 ZIP: 533 B '
<br /> Email and/or Fax: /� ` ,40,, Z,/i-2A , .
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> ❑ Door(s) emodel 0 Fire Damage MCWD review& permits:
<br /> ❑ Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 15320 Minnetonka Blvd
<br /> 0 Re-roof,cedar 0 Restoration 0 Water Damage Minnetonka, MN 55345
<br /> 0 Re-roof,other(specify) 0 Siding ❑ 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) $ �D�I>
<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 /> you refuse to suppl the i .rmation,the a lication ma not be issued. /
<br /> Applicant's Signature: *# Date: 3��5//
<br /> Owner's Signature: Date:
<br />
|