2012-00385 (door replacement) - Laserfiche WebLink

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v��y v� v� v..v �, �Building Permit Application for Maintenance / Renovation (windows, doors, sidin , re-roof, etc.) Mailing Address: Permit number: O,�Q�O PO Box 66 /Q �_ Crystal Bay, Mfd 55323-0066 Dete received: Jf � s' � Street Addres� Received by: � ,� 2750 Kelley Parkway Rlan review fee: �'1 4�� Orono,MN 55356 �j Ax�A�� Total Fee: ��-� oL� �� Main: 952-249-4800 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required Information must be submitted. Incomplete applicatlons wlll be retumed. (Please prirrt) GENERAL INFORMATION: Job Site Address: C�yS� a'� �� • Will thls be a Parade of Homes, Remodelers Showcase Home o�other D(splay Home? Yes ❑ No If yea,a speclal event permif Is requlred wfth Polk:e Depertment end Clty CouncN approva160 days prfor to the event. ShvtNe bus seivlce w!I!be requir+sd unless appNcant demonstretes su�cient on�lte parking is avallabfe. Non pernutted events wlll not be ellou�d. CONTRACTOR I APP�tf:oNT iNFnRMATiON: Name: , f — �qO1� CU•�'`G�� I�t �S51j,: State License# Expiration Date: 3 j3 ! Lead Certification Number: ��'j_ a-�- aB3—) Expiratlo� Date: y/�S (for work on homes that were constructed prlor to 1978 (Cell) Phone: �OSI -o1(Dy-4�� (office} Mailing Address: i9ao Cd 1� ��C e� W,�s�. City: v��1t Z�P� rY11V $Sl�?j Contact Person: Applicant is; Contractor / Homeowner �ci�ie o�e� Email and/or Fax: PROPERTY OWNER INFORMATION: Narne: mp�.�� j O�IM�' Phone (day): g� �. �l��—QIO I ZIP: Address: �g;�.� C�' Email andlor Fax PROJECT INFORMATION: Type of Project: My earth mov�ement may require MCWD review�permits: �Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed Districi(MCWD) ❑ Re-roof,asphaH ❑ Repalr ❑Storm Damage 18202 Minnetonka Blvd Deephaven, MN 55391 ❑ Re-roof,csdar ❑ Restoration ❑Water Damage phone: 952-471-0590 ❑ Re-roof,other(specify) ❑Siding ❑Other. (speclTy) Fax: 952-471-0682 www rninnehahacreek.ora ❑Vlrndow(s) OverallProjectDescription: 01 c�� S � � ' Estlmated Construction Valuation of ProJect excluding tand $ � 4� APPLICANT ACKNOWLEDGEMENT: . Agrees to provide all information required or requested by the Building Department; • CerUffes ihat 1he infoRnation supplied Es true and coRect to the best of his/her knowledge. The applicant reoognlzes thffi lhey ane sdely responslble for submitttng a complete applicalbn being aware that upon Failure to do so, the staff has no altemative but to reject it until It is complete; . Sorne or all of the information that you are asked to provide on this application is classlfled by State law as elther privaie or confidential. Private data ls inforcnatlon which generally cannot be glven to the public but can be given to the subjec�of the data. Confidential data is informatlon which generally cannot be glven to either the public or the subJect of the daia. Our purpose and intended usQ of thls (nformatlon is to annuslly update our records and reoards of other govemmental agenaes r+e uired b law. IF u refuse bo su I the(nformation the a lication ma noi be issued. Aoolicant's Sianaiure: �� Date: ��'�a Z 'd 06T9fiL9TS9 3�Ih?J3S 1IW213d Q '8 S �I 6� �ST ZiOZ 60 FeW