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- , City of Or no Building Permit Appfication for M intenance / Renovafion ; (windows, doors, siding re-roof, etc.) �— Mailing Address: � Permit number. oC0//—D�� / �.,�,� PO Box 66 j Q � � Crystal Bay, MN 55323-OQ66 Date received: /0 �/ i 3,�y ��\� � ;t �',�� ) Street Address: Received by: \�., � �'��,_ �ti 2750 Kefley Parkway Plan review fee: t9g' f�4ti Orono, MN 55356 � ESHD �� _--- Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.or no.mn.us This application form must be completed in full an all quired information must be submitted. Incomplete applications will b� ret rned. (P/ease print) GENERAL INFORMATION: , ' ? � �i� � S—z-/ Job Site Address . -� 1�� : ` . ' � � ) �� %�/�; Will this be a Parade of Homes, Remodelers Showcase Home or ther bisplay Home? ❑ Yes �No If yes, a specral event permit rs required with Police Department and City Council pprova/60 days prior to the event. Shuttle bus service wil/be required unless applicant demonstrates sufficient on-site parking is a ilable. Non-permitted events wil!not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: State License # Expiration Date: Lead Certification Number: Expiration Date: (for work on homes fhat were constructed prior to 1978 Phone: (office} (cell) Mailing Address: City: ZIP: F Contact Person: ppli ant is: Contractor / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: `� G�� .- `�. Phone (day): �j �'� � '� C l / 3-� l Address: ` c.� (� � S ��(� /2�� City. v L-�;,: C�, ZIP: �� > � t Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s} ❑ Remodel ❑ Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damag 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other s eci Phone: 952-471-Q590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �]Window(s) www.minnehahacreek.orq Overall Project Description: (%�,, 5 �((� =�;�55 � r ��; � � �� ,f Estimated Construction Valuation of Project(excluding land $ �� APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Buildi g Department; • Certifies that the information supplied is true and correct to the bes of his/her knowledge. The applicant recognizes that they are solely responsible for submitfing a complete application b�ing a are that upon failure to do so, the staff has no alternative but to reject it until it is complete; ' • Some or all of the information that you are asked to provide on th s application is classified by State law as either private or confidential. Private data is information which generally cannot b given to the public but can be given to the subject of the data. Confidenfial data is information which,generally cannot be iven to either the public or the subject of the data. Our ' � purpose and intended use of this information is to annuall� updat our records and records of other governmental agencies � re uired b law. If vou refuse to su I the-informafion,�he 3 licati n ma not be issued. ApplicanYs Signature: - — -- .-� `= �' .�? -� ,fZ // Date: ��/— �� ' ast Updated: 08-09-2011