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. - Cii� of (�ronc� � Building Permit Application forr IVtlaintenance / Replacement / Renowatio�n (No structural expansion. Qnly windows, daars, siding, re-roaf, etc.) �O��.. Marlirrg Address: Permit number:� � �-- � �VO\ P�Bax 66 Crystal Bay, A�1N 55323-UQ66 Date recelved: � � Streef Rddress: Rec�ived by: _ � �� , � � : �- 275t7 Kelley Pa�rkway Plan review fee: {{�� , f� �. ` ' Orona,MN 55356 �4 - ��kF.ti ri��ti�,� l i ��.7S �_�' Total Fee: Main: 952-24�-464Q Fax: 952-249-4616 w4wv.ci.orono.mn.us This applicatian form must be completed in full and all required info�mation must be submitted. Incomplete appfications will be returned. (Ptease prinf) GENERAL INFORMATIO : Job Site Address: � ��'J � �� "S �� y�l/� U�E'+-� " �� ^i f S 3'I P , � Will this be a Parade of Homes, Remodelers Showcase Home vr ather Display Home? Yes No ff yes a specia!event permrt is�equrred with Pofice Departrnent and City Councrt approvat 60 days prior to the event. Sh�dtte bus service wifl be requrrec�unless appfrcant deirxxasba[es sulhcrent on-sde parking�s avarf�bte Non-,r�errnrtted even7s�vN!nol be aflowed C�NTRACTdR!AP LtCANT INFORMQTION: Name: i - � `�`'�S C �� L�f f--v'�1� ft �4� (�� State License# j L � �� @� Expiratian Date: Lead Certificatian Number: Expiration Date: (for work on homes thaf were constructed pNor to 1978 � �� Phone: (cell) ;�f.� — �'1�,�� -.16/�? (o�ce) Mailing Address: y �/ �(,�. Sf-�;� � City: .'Li �L,�-f.,�. IP: SS3`rS Contact Persvn: �� j�4 c'� Rppdicant is: ont / Homeowner cce��or�� Email andlor Fax: a�,B��,�5 Lv�,s�.�'k �f h-�, . Cc�� PROPERTY OWNER IF�FQRMATION: Name: ��'� � � Co�'Sa`, __.�_________--T-- ----- ------ Phone (day): C/ol "�, i,� ---�.7� S Address: l a7� Ch �'�y C�u�r= 0� "�! Clty: O �"a `'r � ZIP; S � �,9 ( Email and/or Fax: PROJECT INFORMATION: Overall project description: ll�'��r �C�'a�r',: ��'P��(' � e'C��y/ a�l ��5 Type of Project: i Any earth ma�emer�t may afso require s{�/. ❑Door s i MCWD review&pernnits: ( } ❑Remodel ❑ Fire Damage � //��f' ❑Re-roof,asphalt �Repair ❑ Storm Damage � Minnehaha Creek Watershed District(MCWD) �� ( 18202 Minnetonka Blvd ❑ Re-roof,cedar ❑Restoratian ❑Water Damage � aeephaver�,MN 55391 ❑ Re-raof,ather(specity� ❑ Siding ❑ Other:(specity) � Phone: 952-471-0590 , Fax: 952-471-0682 ❑Windov�r(s} �C��= �'�"�� www.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land� $ :��?� . u" APPLICANT ACKN�WLEDGEMEWT: , _ _ _ __ _ _ .__ __ __ _ _ __ � . Agrees to provide all infarmation required or requested by the Building Department; i ' • Certifles that the information supplied is true and carrect to the best of his/her knowledge. The applicant recognizes that they are ; solely responsible for submitting a complete application being aware thst upon failure to da so,the staff has no altemative but�o ' reject it until it is complete; ' • Some or all of the information that yau are asked to provide on this application is cJsssified by State law as either pnvate or j� cnnflderrtlaL Private data is information which genersify cannot be gi�en to the publi�but can be gl�en ta 4he subject o�the data. Confidential data is information which generally cannot be g"rverv to either the public or the subject of the data. Our purpose and I intended use ot this'rnformation is to annually update our records and recards of other governmental sgencies required by law. If I you refuse to su�pl the information,the application may not be Issued _____._ ___.-- _-.----___-- --.. - - --_- _.._ � ApplicanYs Signature: � Date: � � a v% � r �� g!d9��d Owner's 5ignature: �'" ��"�} �ate: Last Updeted 03/Q6/2�13