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���y o� Qro�o <br /> ' �'uil�ing Permit Appiicafior� for Mainter�ance / Renovation <br /> (windows, doors, siding, re-ro�f, etc.) <br /> M,ailing Address: Permit number: <br /> ��v D,hp PO Box 60 <br /> /o �\` � ` Crystal Bay, MN 55323-0066 Date received: <br /> , � <br /> a �,��" � ' Street Address: , Received by: <br /> ''"�, � ������ 2750 Kelley Parkway Plan�rreview fee�: � � <br /> L9kEsH04 Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 wwv��.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incompfete appfications will be returned. (Please print) <br /> GENERAL INFORMATION: z� f <br /> Job Site Address: '"�.�-S `�� � ,�l f� �Li <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> If yes, a spec�a/event permit is required with Polrce Departmenf and City Counci!approval 60 days prior to the event. Shuttle bus service wil/be <br /> required unless applrcant demonstrates suffrcient on-site parking is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/A PLICANT I OR ATIOI�: <br /> Name: �--���� ���ar.3 � <br /> State License # o ' �j Expiration Date: '� <br /> Lead Certification Number. Expiration Qate: <br /> (for work on f�omes fhaf were constructed prior to 1978 <br /> Phone: 's`� �- C (office) (cell) <br /> Mailing Address: City: .c - `-�.71P: J <br /> Contact Person: � ��N Appfica�t i . Contractor l Homeowner (Circfe One) <br /> Email and/or Fax: ;�; � 9-�-' <br /> PROPERTY OWNER. INFORMATION: <br /> Name: ` �C �.�� <br /> � <br /> Phone(day): 2 — �t�- ,_ L C�U� ' <br /> Address: �Z� �� Q P �� City��� �1� ZIP� ���'j <br /> Email and/or Fax <br /> PROJECT INFORMATIOI�: <br /> Type of Project: Any earth movement rrzay require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Qamage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-Q590 <br /> `�-I�e-roof, other(spec� ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> `,� <br /> 0 Window(s) i www.minnehahacreek.orq <br /> Overall Project Description. �'�, <br /> Estimated Construction Vafuati n of Project (exciu ng land) $ '77� V�;� �-- <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The appficant recognizes that they <br /> are soiely responsible for submitting a compfete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it unfil it is complete; <br /> • Some or all of the informafion that you are asked to provide on this appfication is classified by State law as either private or <br /> confideniial. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidenfial data is information which generalfy cannot be given fo either the public or the subjecf of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to u fv the informafion,the ao fication ma not be issued. <br /> . ; <br /> ApplicanYs Signature: Date: <br /> Last Updated: 08-09-2011 ��L��{��r�� <br /> � L � U���J <br />