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From:Traci LeFfier Far,:f952)920-9520 To: Fax: +1 (952j 249-4616 Page 2 of 4 1112d/2015 2:51 PM
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<br /> City af 0►rono
<br /> E3uilding Per�mit Application for Maint�nanc� / Replacement / b�:ernod�l
<br /> (i.e. windows, doors, siding, re-roof, etc, -� NO ;�T'RUCTURAL EXP�►IVu�IONj
<br /> ..__.__. W..�._�.,
<br /> '�` ��y�.,r Mailing Address �/�J�.'� � �
<br /> �� ��d V \ PO Box 66 Permit�umber: Q� r`��
<br /> %/ � � Crystal Bay, MN 55323-Oa66 Date receiued ��__� ��
<br /> ; �
<br /> � Received b
<br /> �, ,� Stree.t�4ddress: Y� _ _ _ _�
<br /> ��� ,;^% 275Q Kelley Parkway Plan rewew fee. 1����
<br /> `<,�� ��L�G% Orono. MN 55356 %_— e__._W
<br /> ,� F�t��� j �,//'�
<br /> ---- --- -- — ----------- ---- _ _7otal Fee. �`---- ---
<br /> Main: 952-249-4600 Fax. 952-249-4616 www ei.arono.mn_as
<br /> This application form must be completed in ful�and all required information mus e submitte��.
<br /> Incomplete applicatinns will be retumed. (Please print)
<br /> GEMERAL INFQRMATION: l /� �. ;
<br /> Job Site Address: ��i���+�� ��'�C.��,, �l�.
<br /> Will this be a Parade of Momes, Remodelers Showcase Hom�c,r other[)isplay Horrte? ❑ Yes ^��� ��o
<br /> !f yes,a special event permit is required with Pc;iC�°Department and Ciky Gouncil approval 60 days prior to the event. Shuttle bus seivi�ce witl be
<br /> required un/ess applicant demonstrates suffident on-site parkrng.,is available. ,Non-permiYfed events wi11 not be allo,ved.
<br /> COtdTF2ACTOR!APPLICANT fNFORMATION:
<br /> Name: �t�� �..�`'�.�,v���"'.� -�r'1.�:_
<br /> State l.icense# � �l�;��.�(ft�—� �� � � Expiration Date: =?, ��, �
<br /> rt.. +�} �.� .� , � Ex iratiun Date� '�^-!��
<br /> .�_
<br /> eacl ertification Number �_ �T- p �� .�,, ---- ---- ____ p --�/�a����-,C�_._
<br /> _��s �.
<br /> (for work an homes that were canstructed rior fo 1978 ,
<br /> Phone (cell) �.�.`-� � �f� ���i �.'� (affice) �v�<� �`��'�' `o��f j j
<br /> MailingAddress: �:�-�:s��i'4�,���1 � -- _.,_ Cify� �°�...��.�'ra (���5.� ��, t�
<br /> �-----�a �.
<br /> Contact Person: �'(�j��(�,,�� ��,,�, AppJicant is: Contractor / Homeowner �c�«ieo�e�
<br /> Emaii and/or Fax � � �� �- �l"t �i�- �,a'`ds�'��' �
<br /> �. '�.��'_rrft r.:°r�t� i�-, .__,...�._,g',� ��.___ ------- '
<br /> PROPERTY OWNER 1 FORMATIQ.(V: q
<br /> Name: ���£��j�-��'�1/t°2.1 t __..._.—
<br /> _-- -- -------._— ___._ __�__..___.....
<br /> Phor�e(day): —���--����-
<br /> Address: ����' � �' �l`�-�t'��"'� _ _,_ City.��' ; ZIP '�'�y �'
<br /> CJ'_L�.L:___ ���.,��f--
<br /> Email andlor Fax:
<br /> PR�,lECT INFORMATiON: Overall pro�=ct description:
<br /> Type of Project� J �� ��T-- Any earth movemen4 may also�require ��
<br /> ❑D�or(s} ❑ Rerr�odel ❑ Fire Damage MCWD review&permits: ! ,
<br /> �e-roof,as halt � Minnehaha Creek Water;hed Di>trict{MCWD)
<br /> p ❑ Rep�ir ❑Storm pamage- 18202 Minnetonka I31vd
<br /> ❑Re-roof,cedar ❑ Restoratipn ❑Water Damage l�eephaven,MN 5�391
<br /> I ❑Re-roof, ather(specify) ❑5iding ❑C>ther. (specify)" �'hone: 952-471-O:i90
<br /> Fax: 952-471-06t32
<br /> �I ^ ❑Winciow(s) www.rninnehahacreek_o� '
<br /> I�.—�____._.__- -
<br /> � ��w� --- ------------- -----__-----..
<br /> Estimated Construction Valuation of Project{exc(uding land}� $����"},�"=a��°} __� ��
<br /> APP�ICANT ACKNOWLEDGEMENT: `
<br /> • Agrees to provide a!I information required or requested by the Building Departn�ent; � � � �v�
<br /> • CertiPies that the infarmation supplied is true and correct to the beat�f hisfher knowlEdge. The app(icant recognize��tnat they are
<br /> solely responsible for submitting a cornplel�e application being awdre that upon failure to do sq the staH has ro alternative but to
<br /> reject it untif it is complete; �
<br /> • Some or all of the information that you are asked to provide on this applic�ation is class�fied by State law ;�� e+iher private or
<br /> confidential. Private data is information which generally cannot b�given to the public but can be given to the subject of the data
<br /> Confidential data is infarma;ion wF�ich gene�ally cannot be given to eitner the public or the subject of the data. Our purpose and
<br /> intended use of this information is to anr�uaHy update our records and records of other governmental agencies requ red by Izw. If
<br /> _ yau refuse to su I �"e'infor �rtion,the � Ii^ation maLnot be is�ued.
<br /> A�plicant's Signature: �� '' ^�-�.. i�� Date:� ��O J __�_ �— -
<br /> Owner's Signature: __��___ ____ Date __ �����_T
<br /> Las1 Updafed:January 2015
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