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�,�r` ,\�/ City of Or no �'�0 Building Permit Application for aintenance / Renovation (windows, doors, sidin , re-roof, etc.) Mailing Address: Permit number: D - d bL�g Og,�,�.0 PO Box 66 Crystal Bay, MN 55323-0066 Date received: � ' �"��a—' ��. ,� 1 �; �-�_ �, Street Address: Received by: �'�c, ' ` � Gti�' 2750 Kelley Parkway Plan review fee: �.��Hog� Orono, MN 55356 , / — Total Fee: �J�-��v . / 7 Main: 952-249�600 Fax: 952-249-4616 ��^�w.ci or r�o mn u� This application form must be completed in full and all quired information must be submitted. Incomplete applications will be ret rned. (Please print) GENERAL INFORMATION: Job Site Address: �(� SI � p4 Will this be a Parade of Homes, Remodelers Showcase Home or ther Display Home? ❑Yes No If yes,a specra!evenf permit rs requrred with Police Department and City Council proval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is av ilable. Non-permrtted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: N�me: "�'�� • S. � S IJIo ri�J' 1�J�. State License# � —)� � Expiration Date: 3�?,j-�Z Lead Certification Number: � �-�� Expiration Date: �j`—Z�,�5 {for work on homes that were constructed prior to 1978 Phone: C'SZ— 2Cj' ; 0� (office) �,j —��b— (cell) Mailing Address: Z2 zSl 32�'� � 4��— City: � Q�S ZIP: �y�(1, Contact Person: �E�.� ��c, Appli nt is: ontracto / Homeowner (Circle One) Email and/or Fax: r `�� ` 4 - PROPERTY OWNER INFORMATION: Name: � � , •� Phone(day): �p(2—�(� ' y�Gg,°o Address: - City: � ,,�Cj ZIP: ��3,�j Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) [�Remodel ❑ Fire Damage N�CWD review 8�permits: � , Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orca Overall Project Description: Estimated Construction Valuation of Project(excluding land) $ "�;�`) .��- APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building epartment; • Certifies that the information supplied is true and correct to the best o his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being awa that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this a plication is classified by State law as either private or confidential. Private data is information which generally cannot be gi n to the public but can be given to the subject of the data. Confidential data is information which generally cannot be giv to either the public or the subject of the data. Our purpose and intended use of this informati is to annually update ou records and records of other governmental agencies r uired b law. If ou refuse to su I t rmation,the a lication a not be issued. ApplicanYs Signature: � �, / Date: �� -j 2 Last Updated: OS-09-2011