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. City of Or no Building Permit Application for M intenance / Renovation (windows, doors, siding, re-roof, etc.) Mailing Address: Permit number: �O /— �j,0� PO Box 66 Q �a O ,, Crystal Bay, MN 55323-0066 Date received: � ,� �-s� ,, � Street Address: Received by: � " � ti�' 2750 Kelle Parkwa ��t v t `'"� � Y Y Plan review fee: 9kESH�� Orono, MN 55356 � Total Fee: /��,�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.oro o.mn.us This application form must be completed in full and all r quired information must be submitted. Incomplete applications will be ret rned. (Please print) GENERAL INFORMATION: "`� �— � Job Site Address: _ ` � i� Will this be a Parade of Homes, Remodelers Showcase Ho e or ther Disp ay Home? ❑ Yes ❑ No � If yes, a special event permit is required with Police Department and City Council prova/60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is av ilable. Non-permitted evenfs will not be allowed. CONTRACTOR/AP�ANT INFORMATION: , Name: -��, - ;�-r �-� State License# �v � � � Expiration Date: �--��---lf Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: �j;� �-J �•� b � (office) (cell) Mailing Address: �� City: �l� �;�tw,,a� ZIP: j�� Contact Person: �� Applic nt is: �ntrac�r / Homeowner (Circle One) Email and/or Fax: ' — PROPERTY OWNER INFORMATION: Name: `�� ; ��c. �,�� Phone (day): Address: City: ZIP: 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 Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Description: �'z��, Estimated Construction Valuation of Project(excluding land) $ p APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Buildin 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 submitting a complete application being 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 thi application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential 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 inform on is to annually updat our records and records of other governmental agencies re uired b law. If ou refuse to s I .t information,the a licati n ma not be issued. � '�� '-z � �- l� ApplicanYs Signature: Date: Last Updated: 08-09-2011 I I