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. ���y af Q ro n o <br /> B�il�ing Permit Applica�ion for Nlainter�ance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: ! <br /> �%�v 0� PO Box 66 I Permitnnumber. <br /> �/� O�� Crystal Bay, MN 55323-0066 Date received: <br /> � �� <br /> �a -�' s, Street Address: (-Received by: <br /> ��r,� <br /> �� � ,���'a� G�� 2750 Keliey Parkway Plan:review fee: <br /> ��Rg �4`�� Orono, MN 55356 � <br /> ESH� <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 wv✓w.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> incompfete app(ications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � � C��S�� C�J�Q� 2e� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> !f yes, a special event permit is required with Police Department and City Council approval 60 days pnor to the event. Shuttle bus service wil!be <br /> required unless applicant demonstrates suffrcient on-site par'King is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/AP�JAI�T INFO MATIOf�: ' i� <br /> Name: '�g��„� � ` <br /> State License # (,(;�� �� Expiration Qate: 'j � <br /> Lead Certification Number: �di'��� ^� /� � Expiration Qate: <br /> (for work on itomes that were const cfe�rio 0 1978 <br /> Phone: ���''� 2�����6 (otfice) �>l 2 �-j'�f' —' ���� (cell) <br /> Maifing Address: (�L�' S'V�,�,�y2Q�,j �2 City: ��� �n��,�ZIP: � ��P� <br /> Contact Person: ,� .' '�—� <br /> r�-- C / Applicant is: Con�tor / Homeowner (Circle One) <br /> Email and/or Fax: iv��?f-�. � ;�•�,j� [�.e S-�� �y S_ ��, <br /> PROPERTY OWNER INFORMATIOf�• <br /> Name: L. l' (�� (�,,� <br /> Phone(day): � - <br /> Address: ���� �S G'y �� � City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: � Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Qamage MCWD review&permits: <br /> � Re-roof, aspha�t �J Re air Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Storm Damage 18202 Minnetonka Blvo <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other s eci Phone: 952-471-0590 <br /> ( p fy) ' ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 <br /> ❑ Window(s) � www.minnehahacreek.ora <br /> I � <br /> Overall Project Description: � �- � <br /> Estimated Construction Valuation of Project (excluding land) � l(���-�D <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 app(icant recognizes thaf they <br /> are soiely responsible for submitting a compiete application being aware that upon failure to do so, the staff has no alternative <br /> Ibut to reject it until it is cornplete; <br /> • Some or all of the informafion that you are asked to provide on this application is cfassified by State law as either private or <br /> confideniial. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the <br /> I data. Confidential data is information which generally cannot be given to either the public or the subject 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 bv law. If ou refuse to su f tne information, the a pfication mav not be issued. <br /> AppficanYs Signature: ���� � <br /> , Date: � <br /> �ast Updated: 08-09-2011 <br />