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VI�y VI VI VIIV Building Permit Application for Maintenance / Replacement/ Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) O � Mailing Address: Permit numbec O ` �� 2 � �� F �/�, PO Box 66 Crystal Bay,MN 55323-0066 Date received: �� ' �-� � ^ 1 1� Street Address: Received by: �/ 2750 Kelley Parkway Plan review fee: ��c � �� Orono,MN 55356 ��KF�Fii��t�� Total Fee: �.5 I Main: 952-249�600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications wlll be returned. (Please print) GENERAL INFORMATION: - Job Site Address: i %i � �� G Will this be a Parade of Homes,Remodelers owcase Home or other Display Home? Yes No If yes,a special event permif is 2quired with Police DepaRment and C�ty Council approval 60 deys prror fo Me even[ Shuttle bus sarvice wdl be 2qurred unless applicant demonstretes su/hc�ent on-sde parking is evailable. Non-permitted events will not be ellowed. CONTRACTOR/APPLICANT IN�ORMATION: Name: �,.� �, �3�` rc •��.v ��< State License# � Expiration Date: '"' — Lead Certification Number: - Expiration Date: - w (for work on homes that e construc� nor to 1978 Phone: (cell) j �� (office) _ Mailing Address: � 7-1� /j City. '' A��,l'i�Z�P: . .S Contact Person: �/�; �7 i Applicant is: Contractor / Homeowner �cimie one� Email and/or Fax: �JS� �,,�r f-� ��-�Q[�On LL C �-��" PROPERTY OWNER INFORM�T� Name: D.i�,'� .Ar" � �u r Phone(day�:l.•�.I X,�� ,�� - �,y,� � Address: /Jc+u L'a1. �-R�^ R�A � City: �nv�v� ZIP: ��j�j � Email and/or Fax: �� J �fjJ (.'��M PROJECT INFORMATION: Overall ro ect descri tion: I Type of Project: Any eaRh movement may also require ' ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permits: ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed Distrid(MCWD) 18202 Minnetonka Blvd ❑Re-roof,eedar ❑Restoration ❑Water Damage Deephaven,MN 55391 � ❑Re-roof,other(speclry) ❑Siding ❑Other.(specify) Phone: 952-471-0590 � Fax: 952-471-0682 � ❑Window(s) (35r�rt /'��nl�S� vvww mmnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . CeAifies that the information supplied is true and corred to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete applicaGon being aware that upon failure to do so,the slaff has no alternative but to reject it until it is comptete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidentfal. Private data is information which generally cannot be given to the public but can be given[o the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this inforniation i ually update our records and records of other govemmental agencies required by law. If ou refuse to su I the infor on,the lication ma not be issued. ApplicanYs Signature: Date: �� ' Owner's Signature: Date: