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C��y af Q�-o�o <br /> �Buifding Permit Appiica�ion for Nlainter�ance / Renovation <br /> (windows, doors, siding, re-ro�f, etc.) <br /> Mailin Address: /� � -- - <br /> 0 PO Box66 Permitnumber. %�'� �� -C �-�:�i���� <br /> �� � <br /> /� � ��I Crystal Bay, MN 55323-0066 �: Date received: ���G�IG�. <br /> I`a � ���,-� �, Streef Address: �1" '�'1'(/ Received by. �(� <br /> \�'�n t��' ti� 2750 Keile Parkwa �' � r <br /> � Y Y Plan review f e: (, � <br /> t`�kEsxo4'� Orono, MN 55356 �� <br /> Totai Fee: / _��� �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us IP <br /> This appfication form must be compieted in full and all required information must be submitted. <br /> incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: , <br /> Job Site Address: '�._�;' ��sr /��t c��� G � r <br /> Will this be a Parade of Homes, Remodeiers Showcase Home or other Display Home? ❑ Yes [}i�o <br /> !f yes, a specral evenf permit rs required with Po(ice Departmenf and City Council approval 60 days prior to the event. Shuttle bus service wil!be <br /> required unless applicant demonstrates suffcient on-site parking is available. Non-permitfed events wil/not be allowed. <br /> CONTRACTOR/AP ICAN INFORMATIOI�: <br /> Name: �/`�(` JLt ; ��� �G9 r <br /> State License # G � � Expiration Date: <br /> Lead Certification Number: Expiration Qate: <br /> (for work on homes that were constructed rior fo 1978 <br /> Phone: 5 Z —y'7yj �—j j � (office) �� 2 Z��D �/ C � (cell) <br /> Maifing Address: �y/ � �u� i ..{.�,,� City: � .C� , ZIP: ��� � <br /> Contact Person: ����'i Appficant is: ractor / Homeowner (Circle One) <br /> Email and/or Fax: \��= j= n��, ,^(�' C�rT` � ��-�l �,C��� <br /> PROPERTY OWNER INFORMATION: <br /> Name: S f �-�,,� 5 j l�5 <br /> Phone(day): c.f"� � ,— � '7 �� a <br /> Address: �j'Z�j S✓ L " ��,� C r`,,— City: �l��..-��— ZIP:S� ��� <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: � Any earth movement rrzay require <br /> ❑ Door(s) [�model ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Re air Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other s eci Phone: 952-471-Q590 <br /> ( p fY) ' ❑ Sitling ❑ Other. (specify) I Fax: 952-471-0682 <br /> indow(s) www.minnehahacreek.orq <br /> Overall Project Description: ;,� �,�; j„� �Y.,�:S '� � S�y,.p.� �� <br /> Estimated Construction Vafuation of Project (excluding fand) $ Z vi� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide al!information required or requested by the Building Department; <br /> • Certifies that the informafion suppfied is true and correct to the best of his/her knowledge. The appiicant recognizes that they <br /> are soiely responsible for submitting a complete applicafion being aware that upon failure to do so, the staff has no alternafive <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confideniial. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> � purpose and intended use of this informafion is to a u Ily update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to I the informa , e ao lication ma not be issued. <br /> AppficanYs Signature: C� ��1 <br /> Date: �- (J � <br /> Last Updated: 08-09-2011 <br />