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� . �i��► v�� 4r �o �uiiciing Permit �ppii�a�io� for aintenance / E�eno�a�ion (windows, cioors, siciin , �e-roof, etc.) Mailing Address: � Permit number: / _ /'Q�.�0,� PO Box 66 /� Q Crystal Bay, MN 55323-Q066 Date received: � � � ( �,�3�ar�. �a �' '-�` �, � Street Address: Received by: �� '�;�'' ti �, �� ti 2750 Kelley Parkway Plan review fee: t�s.tfEs�`o4`U Orono, MN 55356 I I Total:Fee: 5/ � J� Main: 952-249-4600 Fax: 952-249-4616 www.ci.o ono.mn.us lG � This application form must be completed in full and all required information must be submitted. fncomplete applications will be re urned. (Please print) GENERAL INFORMATION: � Job Site Address � `' �� ,� , Will this be a Parade of Hor�nes, Remodelers Sh wcase Home o other Display Home? ❑ Yes ❑ No If yes,a specia/event permif is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be required unless app(rcant demonstrates sufficient on-site parking is a ailable. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATIO�l: i Name: ��1�� 7='�'1�� p�i�y ?'� State License# � � _ ` .� � Expiration Qate: � 7 Lead Certification Number: Expiration Date: (for work on homes thaf were consfructed prior to ?978 Phone: ��—,�— z��/ _ .� (officeh (cell) Maifing Address: �_ �� !'� �.- . � �, Cit : ZIP: � > Y _.__� '1 c,��/�w ��/ Contact Person: /'�.,�( Appfi ant is: Cont�ct� / Homeowner (CirdeOne) � Email and/or Fax: � ��; t ��; _ � � �.,/ PROPERTY OWNER INFORMATION: Name: �,-i , ' ��4— i��, Phone (day): Address: City: ZIP: Email and/or Fax PROJECT INFORMihTION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair Storm Damage 18202 Minnetonka Blvd �Re-roof, cec�ar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other s eci Phone: 952-471-Q590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orp Overall Project Descripfion: Estirnated Construction �laluation of Project(exciuding Eand} � '' '� � � — APPLICANT A�KNOWLEDGEM�NT: • Agrees to provide all informafion required or requested by the B�ildi g Department; � I • Certifies that the informafion supplied is true and correct to the bes of his/her knowledge. The applicant recognizes that they ' are solely responsibie for submitfing a compfete appiicafion be�ng a are that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the informafion that you are asked to provide n thi appfication is classified by State law as either private or 1 confidential. Private data is information which nerally can be given to the public but can be given to the subiect of the data. Confidential data is informatio� which g 'erally can o be iven to either the pub(ic or the subject of the data. Our purpose and intended use of this in rmation to annual pdate our records and records of other governmental agencies reauired b law. If vou refuse to su I the inf mation,th iicati n v not be issued. ApplicanYs Signature: Qate: �� !ast Updated: 08-Q9-2011 I �