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Building Permit Application for Maintenance/Replacement/Remodei - Residentlal ONLY <br /> , (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSlON) <br /> Mailing Address: Permit number: 0 _-�,? ;` �- _ <br /> ���T PO Box 66 � <br /> � Crystal Bay, MN 55323-0066 � Date received: �, '") � '�� �' <br /> Street Address: ��� R���by. ,%�, f- <br /> y � 2750 Kelley Parkway ��� Plan review fee: <br /> � L <br /> � Orono, MN 55356 � � �7 <br /> ��kfsiio `` Total Fee: <br /> Main: 952-249-460Q Fax: 952-249-4616 www.ci orono mn.us <br /> This apptication form must be completed in full and afl required information must be submitted. <br /> Incomplete applications will be retumed. (Please prinf) <br /> GENERAL INFORMATION: <br /> Job Site Address: 2829 Casco Point Road, Wayzata, MN 55391 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> H yes,a special event permit is required with Pofice Department and City Council approval 60 days pnor to the everrt. Shutlle bus servioe will be <br /> requrred anless applicant demonstrates sufficient on-srte parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: David Wormald <br /> State License# � N/A Expiration Date: <br /> Lead Certification Number: N/A Expiration Date: <br /> (for work on homes ihat were constructed prior to 1978 <br /> Phone: (cell) 952 913 1132 (office) <br /> Mailing Address: 2829 Casco Point Road City:Wayzata : 391 <br /> Contact Person: David Wormald Applicant is: Contractor / omeowner c����e or�e� <br /> Email and/or Fax: david.wormaldCmarklogic.com <br /> PROPERTY OWNER INFORMATION: <br /> tvame: David Wormald <br /> Phane(day): 952 913 1132 <br /> Address: 2829 Casco Point Road �;�,:Wayzata Z,P:55391 <br /> Email and/or Fax: david.wormaid�marklogic.com <br /> PROJECT INFORMATION: Overall ro�sct descri tion: <br /> Type of ProJeci: Any earth movemer�t may also require <br /> ❑Door(s) � Remodel ❑Fire Damage <br /> MCWD review&permits: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed Distrid(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑ Re-roof,other(speclfy) ❑Siding ❑Other: (specify) Phone: 952�71-0590 <br /> Fax: 952�71-0682 <br /> ❑Window(s) www.m+nnenanacreeK.c�u <br /> Estimated Construction Valuation of Project(excluding land) $ 15�0 <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 applicant recognizes tfiat they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to <br /> rejed it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is Gassfied by State law as either private or <br /> confidernial. Private data is information which generally qnnot be given to the public but ca�be given to the subjed af the data. <br /> Confidential data is information which generally cannot be given to either the public or the subjed of the data. Our purpose end <br /> intended use of this information is to annuaNy update our reoords and records of other govemmental agencies required by Iaw, H <br /> refuse to su the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �v1�1.P, �� , d �� <br /> Owner's Si natu�e: <br /> �- ` Date: ..Jt�t�i ���„��O( �, <br /> 9 <br />