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11/13/2014 12: 13 5073566021 AMWW BB PAGE 02/04 Gity ofi C�rono Building Permit Appficatian for Maintenance / Replacement / Renovation (No structural ex �nsion. Only windaws, doors, siding, re-�roof, et�.) Mailing Address: Permrt numbet: �bI —�1 PO Box 66 ��a Crystal Bay, MN 55323-Q066 Dat�reGei�red; �l""��J "� StreetAddress: . f Rebefved by: y �� 2750 Kelley R�rkway �( �/i,y Pk�n r�viHwf�: , `�� Q�w Orono,MN 55356 �/j �>> r� s� �-�i Fee: ��F � Main: 952�49�BOU fax: 952-249-4616 www.ci.orono.mrt._� '� This app�ication form must be completed in fuU and all required informakion must be submitted. Inoampl�te appfications vuill b�returmad. (Please print) GENERAL IN�'ORMATIO r�,1 l Job SiteAddre�s: .�� lA��_ ��n� �G� Wil!thla be a Parade of Homes,Rem4deters Showoese Ftome or other Display Mome? Y�Na !!yes,a sp9Cr�J event pemrit iS�q�lned with Pa1iCe Deparfment end City CounciJ epp�vd!BO days pnor to f!?B 6venl. Shutfle bu5 Servlce will be nyquired unless appliC9nt demonstretes Suf►Jcfent onsite pGrk/ng Is available. Non-pe�mltted event8 Wfll nof be allow2d. CONTRACTOR!ARPLICANT INFORMATION: Name: .� � �-2Y11J L.; State License# � Expiratian bate: Lead Certification Number� �- l(j Z�p �xpiration Date: ��,�T (for work on homes thaf we�e cpnsLvcfed prior to 19T& � Phone: (cell) {�� IP, M�Iling Address:g j,.t W L � City: �. Contact perso�: y� Applicant is: C�ntractor Home4wner (GI►cleOne) Email and/or Fax: , 2. C - PROpERTY OWNER INFORMATI�IV: Name: Phone(day)� � City:��.(1 z1�':�3 I Address: `� 00 � Email a;nd/or Fax: PROJECTlNFORMATION: Overalt ro'ectdescri tion� Yl�� , �L��-� �'«�-� � � �� 1'ype of Project: Any earth movement may a so require ❑Qoor(s) Cl Remadel ❑�'ire Damage MCWD revlew&permit9: [�Re-ropf,asphalt r�Ftepair ❑Storm Damage Allsnnehaha Creek Watershed District(MCWP) 18202 Minnetonka Blvd ❑Re-roof,cedar �Restoration [�Water Ramage Deepha�en,MN 55399 ❑Re-roof,other(spoclfy) ❑Siding ❑Other:(speafy) PFax��952�71 06820 ❑Window(s) �, www.min hacreek,or fstimated Conatructlon Valuation of Projeat(excluding land) $ APPL,ICQNT AGKNOWLEDGEM�NT: . qgrees to provide ali information required or req�ested by tha Building Department; . Certifies that the infiormatian suppli�d is tru8�nd corr�ct to the best of his/her k[iowledge. The applfcant rewgnizes#hgt they afe SOIEIy responsible for submitting 2 Compiete applic�#iCn befng aware that upon faiiur�to do so,ihe staff has n0 aitemative bvt t0 rej�ct it until it ls complete; . Some or all of the informatio►1 that you are asked to provide on this applicafion is Gasssfied by State law as either private or confidentiai. Private d2ta is information whiCh generally carindt be given ta th�publie but can b�given to the subjeCt of the data. Confldential data is Information which generafly cannot be given to�ither the public or the subject af the data. Our purpose and inte�nded use of this information is to annually update our records and records of other govetnmental agencies reqUired by law. If ou refuse to su I th � on, fon ma not be issued. Applicant's Signature: I�ate_ � 1� Owne�'s Signature; Date� R Last Updated�03106I2013