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O 06-20-2016 09:46 Fax 5ervices -�19522494616 �3
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<br /> "� �- City of +C�rono
<br /> Buildfng Permit Application for Maintenance 1 Replacement / Remodel — Residential ONLY
<br /> �(i.e. windows, doors, sidinr�, re-roof, etc. - NO STRUCTURAL EXPANSf�N}
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<br /> ;� A -. MaNing Address: ! .. � �.,
<br /> ' �V����, PO 6ox&B � Permit number: -�C ;...��,.-�_�,___j —
<br /> ,'� '1 Crystal Bay,MN 55323-0066 Dats received; _ � /�C,
<br /> _�-�.�
<br /> i � Received b _ ��-�
<br /> � Street Address.y y Plan review fee: —�
<br /> ��;� '� y, „ �� `�,r� 2750 Kelle Parkwa �
<br /> !,a � �+ r`~r Orono, MN 55356
<br /> �w9lu`, � �
<br /> ' � Total Fee� �Z C��
<br /> �Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
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<br /> This application form rnust be completed in full and all required information must be submitted. - �� r�y� (�
<br /> Incomplete applications will be�etumed. (Please print) '�`'��`�� /�� � �ZL
<br /> GENERAL 1NFORMATION: w „ ,� ,
<br /> Job Site Address: �.�'�� � �.J�,.�_ "`�ti�,�_�V��r'��.�-�' _._���` _______._�_--.......__.
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<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes � Na
<br /> /f yes,a specia/event permit ls requi�ed wrth Police Depertment and City Council approval BO days pnor to the event Shutt/e bus service w�q be
<br /> requi�ed unless applicani demonslrates su�cient on-site paikiny is evailable, Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPL.ICANT INFORMATION:
<br /> Name; � �� � ��� � ����'�� �
<br /> '���.���w�..�� ....._
<br /> � --
<br /> State License# ��,�___� a������ Expiration Date: �';1 •'�fl ^�,q� ��'^'
<br /> � � �� .
<br /> -��-�,.7'� _ _ _. '-���...,.,,,,. _ —
<br /> Lead Certification�Jumber. Expiration Date:
<br /> (for work on homes that were const�ucted pr�ar to t978� '-- �,.T � - � ---- '.^ �
<br /> Phone: (Cell) (ofiice) � 1 �' g�-(c� ��-,— .� _�, ,�_ �.
<br /> . ....._ +.f . �,�
<br /> Mailin Address ' � ,, y �'� � �,���. �M 1 ; ` .�,:�'�,�
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<br /> Contact Person . �� �a�� ,�.�� Applicant is: � 'r�c3mr� h• Homecov+rr7�r (Clrcle One
<br /> � ����~��
<br /> Email and/or Fax �� ..1(`_..�,`N,�,�..._�.�''-��"'�`�'� "�i-' . [...�,_u �.�?(��
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ����_� ,a�;:�'�:'��,�.,,.�`����"��'" -_....___
<br /> , . . .. --- - --
<br /> Phone da � � �- � �� '��S ��.'�.� ��:,� _ _
<br /> �� � � � �._C.:�.�t^�-��w.__ �. ��,..� _..���" _ C�ty: r...,� , ^� +.a Z I P:
<br /> Address: y �~ __ C,� �'�--
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<br /> Email and/or Fax:
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<br /> � � � �� �1� - .
<br /> PROJECT INFORMATION: Overall rc�e�rt desc�i�tsc,rr1 _��� L���,� � � - C�'"
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<br /> Type of Project: Any earth movement may also req ire
<br /> �Remodel MCWU review 8�permits:
<br /> ❑Door(s} ❑ Fire Damage
<br /> ❑Re-roof,asphalt ��Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> 15320 Minnetonka Blvd
<br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345
<br /> ❑Re-roof,other(specliy) ❑Siding ❑Other. (specify) Phone 952-471-0590
<br /> Fax: 952-A11-0682
<br /> ❑Window(s} www,minnehahacreek.orQ
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<br /> .._...._. ...,, -- - _ , __ _ .. ... --- '
<br /> Estimated Construction Valuatwn of Project(excluding land) $ �"� � I,�� [:,;;,a
<br /> APPLICANT ACKNOWLEDGEMENT:
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<br /> • Agrees to provide all information required or requested by the Bwlding Department
<br /> 1 • Certifies that the intormation suppliad is true and correct to the best of his/her knowledge. The applicant recognizes that they are !
<br /> soiely 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 camplete;
<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 gwen to the public but can be given to the subject of the dat8 ,
<br /> Confidential data Is information which generally cannot be given to either the pubhc or the subject of the data Our purpose and ';
<br /> ;ntended use of this information is to annually update our records�nd records of other governmental agencies reqwretl by iaw. tf
<br /> y�u�efuse to su�aply the infarn7G�Uon, the�a�xFifir ritir�i�m�y not be issued.
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<br /> ApplicanYs Sign�ture �.,,�'�__,_W...�,.' ""�'
<br /> . Date. ---�i._ , �:;�...
<br /> „ �� �' � � �,i
<br /> � � �':•, ��� ����` � "� ,���` DaEe: �..� �"� ..
<br /> Owner's Signature _.__-��-;�,',�,�"a"������ ' � ��� � � � � ��"°`�
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<br /> Lasl Updaied:January 2016
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