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�i�� af ��o�o � �;D� r � �uiieiing Perr�it �ppii�a�io� for IV�ainte�ance / f�env�a�ion (windows, doors, sidi�g, re�-�-oof, etc.) Mailing Address: Permit number: �`l— ��,L,0,� PO Box 66 /� O Crystal Bay, MN 55323-0066 Date received: l � / ,�;;�, �u�. I � ' :Received by: ' �� 1�� s, � Streef Address: ��n ` �"`''�� 2750 Kelley Parkway Plan review fee: �LR��w Orono, MN 55356 kEsxo / Total:Fee: � Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �i ,� This application form must be completed in full and all required informafion must be submitted. incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: � /� �� Job Site Address: � � ,� �, �/ „` Will this be a Parade of Homes, Remodelers Si�owcase Home or other Disptay Home? ❑ Yes No If yes,a specral evenf permit is required with Police Department and City Counci!approva/60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufi'icienf on-site parking is avaifable. Non-permitted events wif/nof be allowed. CONTRACTOR/APP(,ICANT INFORMATIOh: Name: �-- �'�. � state �icense# C �3 �q q� � Expiration Date: 3 � �� Lead Certification Number: Expiration Date: (for work on homes fhaf were constructed prior fo 1978 Phone: (office) � �—�� S"—� --� `� 4 c� (cell) Mailing Address: �-� �S— ��,,�� ` (^� City: �(� ��(�f—��ZIP: SM-�*7�0 Contact Person: �� x, Applicant is: Contractor / Homeowner (Circie One) Email and/or Fax: �� ---�� S-'� PROPERTY OWNER INFORMATION: Name: 1> K--,R-� `�-� � l�N�� C �`Ja f1 �e � � Phone (day): — S Address: �C� .2a� j�,,.�-�`,_,!1 �J,lj City: �v�-�'�,l�i�. ZIP: 5' Sr �' � Email and/or Fax PROJECT INFORMATION: Type of Project: � Any earth movement may require ❑ Door(s) ❑ Remodel i MCWD review&permits: ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair � ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration Deephaven, MN 55391 ' ❑Water Damage Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 (�Window(s) wwv��.minnehahacreek.orq Overall Project Description: ( �r S t�'r I l U �4% � �U i=- t,�%' �J c v�.� ,(�C� �.•.� p1.,1,�p �E=,,"t-�� w1 Esfirnated Construction Valuation of Project(excluciing landj $ l�p�� G'a APPLICANT ACKNOWLEDGEMcNT: i • Agrees to provide all information required or requested by the Building Department; ; • Certifies that the informafion supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete appfication being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; � i • Some or all of the inrormation that you are asked to provide on this appfication is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subiecf of the data. Confidenfial data is information which generally ca t be given to either the pub(ic or the subject of the data. Our purpose and intended use of this information..i�'fo ��r ally u ate our records and records of other governmental agencies rea�ired b law. If vou refuse to su I nfor a�ion the a icafion mav not be issued. ApplicanYs Signature: Qate: �� — �� '— �� Last Lipdated: 08-09-2011