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Ci�y of rono ; Building Per�mit Applic�tion for Maintenance / Renovation {windows, doors, siding, re-roof, etc.) ,�-��A�� MailiPO Bo�r66� Permit number r/oy �yO\ Crystal Bay,MN 55323-0066 Date received: '.� `�''"�',i�="�i a,� Street Address: Received by �� i,��" ti 2750 Kelle Parkwa �'� �, -=��'� � Y Y Plan review fee: �^''��5'�'"�° �qkE58�4 Orono,MN 55356 —_� Total Fee: Main: 952-249-4600 Fax: 952-249-4618 tvw�v.ci.orono.mn.us This app{ication form must be completed in fuil and all required information must be submitted. IncompEete applications will be returned, (Please prinf) GEf�tERAL lNFORMATION: Job 5ite Address: � 5 l� � � � C�. Wifl this be a Parade of Homes, Remo eler howcase Home or other Dispfay Home? ❑Yes o !f yes,a special event permrt is requrred wrth Police Department and Cify Council approva!60 days prior to the event. Shuftle bus service will be requ;red unless applrcant demonstrates sufficient on-sr,e parkrng is available. Ncn-permrtted events wifl n,ot be 3Dewed. CONTRACTOR/APPLICANT INFORMATfON: Name: ��. �=�X�� Cr-�S -L l�C� State License# 1��...C�__g�'� '�� Expiration Date: �_"-�',� Lead Certificafion Number. �/jT3ri�;65�� Expiration Date: ��';�y,� (for work on homes that were consfructed prior to 7978 Phone: �_ '..�I/. 5_��-6 {office) �C • -. � �ZsO �cell) Mailing Address: ��- �y� J'� e/5 c,�.� ' �, CitY: i ��, ZIP: "�� Contact Person: ��y� ��5�� Applicant i�: Contractor__� Homeowner (Circie One) Email and/or Fax: �G� �/S dh �i y�J�CKf'C'c�i�7 fc;u�c,. 7.� ;'� �l��- c3 i d'� PROPERTY OWNER INFORMATIQN' Name� ��,r c��n � �� h y /��'��4r�.S Phone(day): Address: �� '�SS % ' '-j$� e � City:�/'�.-;>?�% �_ ZIP: S��S�� Email and/or Fax PROJECT lNFORMATION: 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 ❑5torm Damage 18202 Minnetonka Blvd ❑ Re-roaf,cedar � ❑ Restoration ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 ❑ Re-roof,other(spec;fy) iding ❑Other:(specify) Fax: 952-4'71-0682 � ❑Window(s) www.minnehahacreek.orq Overall Project Description: �/�J�/� � � � ;ry <<� �- r �, j . �'_ .2/c-�.>c� :E;=�2.� Estimated Construction Valuation of Project(ex uding land) �'�'��,� APPLICANT ACKNQWLEDGEMENT; • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are soiely responsible for submitting a compfete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or a[I of the information that you are asked to provide on this 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 given to either the public or the su6ject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If ou refuse to supply tha�fr�for tion,the ap 'cation ma not be issued. " j, / '. � __. Applicant'sSignature: ;G� '��/� Date: � `��/ Last Updated: OS-09-2011 ��