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A � � City of C�rono Building Permi# Applic�tion for Maintenance / Renovation {windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: p�� -b D D O.�I„Q j�.� PO Box 66 Cryst�l Bey, MN 55323-0066 Date received: �' '� a a Street Address: Recelved by: '�, �' G�' 2750 Kelfey Parkway Plan review fee: �yA�sHo�,� Orona, MN 55356 r�,D//� � Totai Fee: / Main: 952-249-46q0 Fax: 952-249-4618 www.ci.orono.mn.us This application form must be compleYed in ful(and all r�quired information must be submitted. Incomplete appllcations wfll be r�rned. (Please print) GENERAL INFORMATION: �� t ` � Job Site Address: � ��- `�C� � Wi11 this b�a P�rade of Homes, Remodelers ShoSrvC�se Mome or other Display WomQ? ❑Yes No !f y�es,a specf�l evenf permlt Is requ�red with PolJca�eFe.tmqnt and CrYy Cpunc!/approva!BO days prlor to the event Shuttle bus service will be regui�d unless applicant demonstrates su�cienl on-site parking is availabl6. Non permined events wlll not be a!lowed. CONTRACTOR 1 APPLICANT iNFORMATION: Name: 1�,�.Wo.\ �y Ar�-�rS�e^r� - - Sta#e License# �,��"�jQq g� Expiration Date: �j f'�1 Lead Certificaiion Number_ (��_ a'�-�$� --� Expirati�n Dat�: �(��r. (for work on homes Ehat wer�constracted prior to 7978 Phone: �S S- o�[p�-�O�- �t,�qn (a�ice) (cell) MailingAddress' �� . � �� (,y_i��- City�'��y�� , ZIP� s�� �pntact�'erson: App�icant is: nt r / Homeowner �ci.�ie o�a� Emall and/or Fax: PROPERTY OWNER INFORMAYIp Name: � �'(-� �i(Y��1(� Phone (day): � �y� � � "�� Address: � �S;-�, City: ZIP: Email and/or Fax PROJECT INF�RMATION: Type of ProJeat: Any earth movement may requlre ❑Door(s) ❑ Rerrtodel ❑ Fire Damage MGw�review&permits� Minnehaha Creek Watershed District(MCWD) ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Mlnnetonka B4vd j�fte-roof, cedar (]Restoration ❑Water bamage Deephaven, MN 55391 Phpne: 962�71-0590 ❑Re-roaf,other(spec�fjr} ❑Siding [�Other: (specityj Fax: 952-471-�0682 �Window(s) www,minnehahacreek.orq Qverall Project Descrip#ion: ��.Q �J�JI r� 1.�� v'� �.Q�(i �j �n ' Estimated Construction Valuatfon of Project(excluding �and) $ �� '�- �j(y,QQ —� APPLICANT ACKNOWLEDGEMENT: . Agreas to p�ovide all information required or requested by the Building Department; . Certifies that the information supplied is true and correCt tp the best of hislher knowledg�_ The applicant recognizes th�t they �re solely responsible for submitting a complete applicaiion being aware that upon failure ta do so, the staff has no alternative buf io reject ft unttl it is complete; • Same or aEl pf the information thai you are asked to provide an this �pplication is classified by State law as either private or w�fidential. Private data is infarmation which generally cannot be given Co the public but can be given to the subj�ct of the data_ Confidential data is information which generally cannot be given t� either the pubilc or the subJect of ihe data_ Our purpose and intended use o4 this information is to annually update our records and records of other govemmental agencies re uired b law. If ou refuse to su I the information,the a lication ma n�f be sssued. Aaokicent's Sianature: �~-� Date: W��