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� City o� C�rona <br /> gu�i�l;ng permit qpp�ication for Mainten�nce / Renovat�on <br /> (windows, daors, siding, re-coof, etc. <br /> Mal1Mg Address: Permlt number' <br /> �,�0�� pQ Box 6B <br /> Crys#al Bay, MN 55323-006fi Date received: <br /> ReceEved by: <br /> � Sfreet Address_ <br /> � 2750 Kelley Paricw�y Plan re�lew fse� <br /> � ° Orono, MN 55356 <br /> ��' Tate�Fe�: <br /> Pv{ain: 952-249�6Q0 Fax: 952-249�516 www.ci.arono.mn.us <br /> This application form must be completed in full and aA required information must be submitted. <br /> Incomplete applications will be returned. (Please prr"nt) <br /> 6EN�RAL{N�'QRMATtON: �O y � C��C � � 1 �� ' <br /> Job Slt�Address: T <br /> Will this be a Parade of Homes, Re�todelers Showcase Hdme or ather Display Home? ❑Yes No <br /> ►iyes,a spe��iaauirsd unless appNCantrodemonstr�Jtas 8ulflC�enton�lte paricln9 s a1veJlab/e�'Non-pe►mitted events wllltnot be&1lpwed����f!bs <br /> CONTRAG"�OR/APPLICANT 1NFORMAI`ION: <br /> Name: �tx�►:_�\ � 'A�{.'��e'r� �"� <br /> state�ic.�nse# '$G1309 `�"},,,� <br /> Expiration Date: � �� <br /> Lead Certificatlon Number: (`j �r a a$3 - �xpiiratidn Date: �J <br /> (for wor/r on homes that were consb'ucted prior to 1978 (cefl) <br /> Phone: (o'�'J�~ r�( . -�{•0`�` �M Aw (oftice) _ <br /> Mailing Address: �q � . 1� `�G" We� <br /> City:'�.p� �1 e ZEP: S5 3 <br /> Contact Person� AppG��nt is: ontra or 1 Homeowner {Circle Ono) <br /> Email and/or Fax: <br /> pROP�RTY QWNEFt 1NFOCtMAT1dN: <br /> Name: � KC"� ��.. � ' <br /> Phone (day). �e 12 � 3 ZIP: <br /> Address: Ciry: <br /> Email and/or�ax <br /> PROdEC7 INFORMA7lON: Any ear�h mQ�ement may require <br /> TYPe of Projact: MCWD r�vlew 8 permits: <br /> ❑ Door(s) �Remodal �Fire Damage Minnehaha Creek Watershed DlsMct(MCWD) <br /> Re air ❑Storm Damage 1$20Z Minnetonka Bivd <br /> [�R�roof,asphalt � P peephaven, MN 55891 <br /> 0 Re-roof,c�dar [l Rastoration �Water Damage p�p�,�: g,2�71-0590 <br /> Sidin [�Other: (speC�4y) Fa�c: 952-471-0682 <br /> ❑Re-roof,other(spBctCy) ❑ J _min eh�hacre�k.o�r <br /> �Window(s) <br /> . - � I <br /> Qverall Pro ect Descri t{on: q„Ce � � ' <br /> Estimated Constructlon Valuation af Pro ect(excluding land) $ _O <br /> ApP�iCAN7 ACKNOw�,EDGEMENT: the Building D9partm8nt; <br /> . Agrees to pro�ide aU information required or requested by <br /> . CsrtHias that the fnforrnaUon supplied is true and correct to the best of h'sslher knowledge. Th� applicant recOgnizes that they <br /> are soleEy responslble t�r submitting a complete application being aware that upon failura to do so,the staff has no altemative <br /> but t0 reject it unfil it is complete; <br /> . So►ne or afi ofi the ir�formatlon th�t you are asked to provide On Shis 8ppllcatian � ublic b�ut can be g ve to th��subject of the <br /> confldenti8l. Pfivate data ls infot'mation Whlch gen6ra�lY cann°t be given to the p <br /> data. Carifldential data is infvRnation whlch generally cannot be given to elther the publlc or the subJect of tt�e data. Our <br /> purpose and intended use of ihls infdrmation �s to annuaAy update our records an8 recards of other govemmenta! agencies <br /> r� uired b law. If ou refuse to su I the Infiormation,the a lication ma not be issued� /� <br /> Date: 1�� � <br /> Anolicant's Sitlnature: �'�� <br />