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, ' �b <br /> � �o�o � <br /> City af Qrono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.} <br /> � Mailing Add�ss: pg��{number. 02 / -� �08 Z <br /> � �� Crysta(Bay,MN 55323-0066 Date recaived: '/ - / � <br /> Street Addisss: Received!ry: <br /> � � 2750 Keltey Parkway Plan reviewfee; 7 �7 <br /> `� 4� Orono,MN 55358 � <br /> `'°kFs Ho�ti ao i�-00��3 <br /> Total Fee: <br /> Main: 952-249-4fi00 Fax: 952-249-4616 vwvw,ci.orona.mn.us <br /> Ti�is application form must be corr�pleted in full and all required information must be submitted. <br /> Incomplete applications witt be retumed. (Please prrnt) <br /> QENERAL INFORMATION: ' \w � <br /> Job Site Address: ` �,�,� <br /> Wil!this be a Parade of Homes, Remodelers Sha case Home or other[?ispiay Homa7 Yes Na <br /> lf yes,s speda/svetrt permit is required with Police Uepartment and City Council approval 60 days prior to the event, Shuttle bus wit!be <br /> requirod un/ess appGcarrt demanstrates suA�ent on-site parking is availaWe. Non-peRnitted everrts wiJi rrat be attower/. <br /> CONTRACTOR 1 APPLc�ICANT INFORMATI�N; <br /> Name: i��fl�.SGLw'E"- Iti�"^�-- �S'�1�f w•.. <br /> State License# Expiratiorf Date: 3�g 1—�sr' <br /> Lead CertificaUon Number. -- 3 s'as�- i Expiration Dete: ,�. 7—/.�; <br /> (for worh on homes that wane consfructed prlor to 1978 <br /> Phone: (celi) 1 (��? <br /> Mailing Address: � � � � City: ZIP: ���-( <br /> Contact F'erson: n � Applicartt is: ontra / Homeowner �ci�m on� <br /> Email and/or Fa7c: �, - � �,��, ,,,., <br /> PROPERTY OWNER INFORMATfON: <br /> Name: l�� �- K�,��✓'�1�.P. ��{v�neSS <br /> PhonB{day): � 1 r a� <br /> Address: ��}� La�S�t,� '��ri�l�( �.I�S�" City: �✓2a1J ZIP: .S3�S� <br /> Emaii andJor Fax: "'�'"t,�nc�s3 �3 1.eJ.w <br /> ��[_;nm <br /> PROJEC7INFORMATION: Overali ro'ectdes ' tlon: � u�. � Q'Ynv � a ; l�� <br /> Type oi Project: Any eart vement may a o require <br /> ❑Door(s) �$emodel ❑Fire Damage MCWD review 8.permits: <br /> ❑Re-roof,asphaft ❑Repair ❑Storm Damage Minnehaha Creek Watershed Distnct(MCWD) <br /> i6202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Resioration ❑Water bamage Oeephaven,MN 55391 <br /> ❑Re-mof,other(specity} ❑Siding ❑Other.(specify) Phone: 952-4�71-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehah�creek.or� <br /> Estlmated ConsM�ction Valuatlon of Project{exc{uding fand) � � <br /> APpUCANT ACKNOWLEDGEMENT: <br /> . Agr+ees ia provide aN information required or requested hy the Building Department; <br /> • Certifies that the i�omiation supplied is true and carrect to the best of his/her knoadedge. The app8cant recognizes that they are <br /> solety responsible for submitti�g a complete appiication being aware that upon failure to do so,the sta�f has no alfemative but to <br /> reJect it untii it is complete; <br /> • Some or a1! of the information thai you ane asked fn provide on this application is classiSed by Sfate law as either private or <br /> confidential. Private data is information which generaliy cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is infarmation which generally cannot be given to eiiher the public or the subjecl oi the data. Our purpose end <br /> intencled use of this information is ta annualiy update our recorcis and records of other govemmenlal agencies required by law. If <br /> ou refuse to su the'nfo an the a lication ma nat be issued. <br /> Applicant's Signafure: - Date: _ '` �"�� <br /> �wnePs Signature: / Da#e: _ 7• � 0•!y <br /> Last Updated:03/0672013 <br /> .___ - -- __-_.- „ - _ - _ .... <br />