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. •. City of Qrono Buiiding Permit Application for Mainten�nce 1 Renovation �windows, doors, sid�ng, re-roof, etc.) Mailing Address: ad� � 0�� ;% -�'� Permit number: � �,0,�� PO BoK 66 �� F O`\�, Crystal Bay, MN 56323-0060" Gate received: /b ,�j i- ��•,� ' � ��f �,i! SireetAddress: Received by: �� `� h'/ 2750 Kelle Parkwa �� .� ��%% Y Y Pfan review fee: \'�g�SKo j Orono, MN 55356 "i Total Fee: ��. ��"� Main: 952-249-4600 Fax: 952-249-4616 wv��v.ci.orono.mn,us This application form must be completed in full and all required information must be submitted. Incomplete apptications will be returned. (PJease print) GENERAL INFORMATION: � , Jab Site Address: _ �'�j �J�°��.��Li ��t f.� ��,2" � Wil!this be a Parade of Homes, Remadelers Showcase Home or other isplay Home? Yes .,..�-la'o 1f yes,a special event permit is required with Police Departmeni end City Courci!approvaJ 60 daya p;ior to the event. Shutffe bus service►aill be required unless applicant demonstrates su�ficienf on-site parking rs avaifable. Non-permitted evenis will not be a!/owed. CONTRACTOR I APPLICANT 1NFORMATION: Name: ��'�� 1 � i`� �--�'l.��r"�; 5tate License# �s��'� Expiration Date: �-� �/ -- �✓%� Lead Certifieation Number: ,i!,/�,i'"�� Expiration Date: (for work on homes that were con�struc et d prior to 1978 Phone: � - y �'� (office) C_� -.,5? c _ „�� (cell) Mailing Address: C;v,�= �,� 3 _ City: � 4? •:�:�,.� ZlP: Contact Person: ,,, a �.;''� -� Applicant is: Contractor / Homeowner {Circle One) Email and/or Fax: �`��. S"!j� ,_ �� ._""�"'"""'• PROPERTY OWNER lNFORMATION: Name: GV r�!/r'�.�'7 /�i��J� Phone(daYl� � .—�-�-- �fL�� – .� Address: � �rr-,�;� City: ZIP: Email and/or Fax PROJECT iNFORMATIQN: Type of Project: Qny earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MC1ND review&permits: Minnehaha Creek Watershed District(MGWD) ❑ Re- f, asphaft ❑ Repair ( ❑5iorm Damage 18202 Minnetonka Blvd Re-roof, cedar ❑ Restoration []Water Darnage Deephaven, MN 55391 Phone: 952-471-0590 ❑R�roof, other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-06$2 ❑Window(s) wvvvv-min�ehaha�reek.ora � Overall Project Description: •��.�',r � '" �°�– Estimated Construction Vatuation of Project(excluding landj $ �yf��,; ,..-= r-�— - -- APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that lhe information supplied is true and correct to ihe besi of his/her knowledge. The app(icant recogn�zas that they are solely responsible for submitting a complete applicat'sor, being aware that upon fiailure to do so, the staff has no altemative but to rejecf it until it is complete; • 5ome or atl of fhe information that you are asked to provide on fhis applicafion is cfassified by Stafe law as either private or confidential. Private data is information which generaliy cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or fhe subject of the data. Our purpose and infended use of this information is to annually update our records and records of other governmental agencies r uired b law. !f you rzfuse_tp. �the+rrforma�ior�>the a lication ma nof be issued. : _._.-..._•---- �-.�"`---G'"..._. . . . ; � —_.._,..,_._ f . / � �j�/ APPl�cant�s Signature: .��-.,--�: c...._.�"'��„ '�--- _. Date: /�j'� � �