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Oct. 13, 2011 9: 24AM AC Construction & Restoratio� No, 5584 P. 1 � City of Or no Building Permit Application for M intenance / Renovation (windows, doors, siding re-roof, etc.) Mailing Address: '�Q.� PO Box 66 P��t nu�nber; L .-�/aZ Q Q Crystal Bay, MN 55323-0066 Dete;Feceived: / � . a Streef Address: Received by: �� 2750 Kelley Parkway Plan review fee; , k�H� Orono,MN 55356 Main; 952-248-4BOD Fax: 952-Z49-4616 www.ci.or no.mn,us Totsl.Fee; .. �,� � �� This application form must be completed in full and all r quired information must be submitted. Incomplete appllcations will be ret rned. (Please pnnt) GENERAL INFORMATION: Job Site Address: �'�� '� S� � e Q��„ Will this be a Parade of Homes, Remodelers Showcase Home or ther Display Home? Yes No lf}res,a spe�ial event permn is requlrod with Pollce Depertmant and C/ty Councfl proval 6a d9ys prior to the ewen! Shuttle bus servtiae wlll be required un�ess eppllcant demonstrates su�cient on�slte paricing ls a ilable. Non permhted evenfs wlll not be allowed, CONTRqCTOR!APPLICANT INFORMATION: Name� � e�5'�'rL� c : ei,n• ��•es State License# V 3 Expiration Date: '3- 3 �- i 3 Lead Certification Number: (� _ � Expiration Date: -1�y.�- ( �, (for woik on homes that were conatrricted prior to 9976 Phone: (;Q '�,. 3 f� �O- �SO (office) cell � ) Mailing Address: �� v F I�r�,,�,� L�, Ci : � Z�p: �•s�-�y Contact Person: '�vr.► � �oN Appli nt is; Contracto Homeowner �ci�e�.o„a� Email and/or Fax: �,p,��,��`�,,,�, /��.C� �. C or�-► PROPERTY OWNER INFORMATION: Name: MA�a.�� a 'S�w► �t.� Phone(daY): �a- �('13- g`f'19 Address: City: Z�p; �mail end/or Fax PROJECT INFORMATION: rype of P�oJect: Any earth movement may require ❑Door(s) ❑Remodel ❑Fire pamage MCWo revlew 8�permlts: Minnehaha Creek Watershed pist�ict(MCWD) roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd ❑Re-roof,cedar ❑Restoration �Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑Re-roof, other(9peclty) []Siding �Other:(specify) Fax; 952-471-0682 ❑Window(s) www.minnehahacreek ora Overall Pro ect Description: Estimated Construction Valuation of ProJect(excluding land) J�'oocs APPLICANT ACKNOWLEDGEMENT; • Agrees to provide all information required or requested by the Buildin Department; • Certifies that the information supplied is true and correct to the best f his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete epplication being a re that upon failure 2o do so, the st�ff 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 application is classified by State law as either private or confidential, Private data is information which generally cannot be iven to the public but can be given to the subject of the data, Confidential data is information which generally cannot be g' en to either the public or the subject of the data. Our purpose and intended use of this information is to annually update ur records and records of other governmental agencies re uired b law. If ou refus su e inf�rmation,the a licatio ma not be issued. Applicant's Signature: Date: 6 U� J�l� Lasl Updated' 08-09-2011