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May. 31.2016 05:04 PM 7633156777 7634281111 PAGE. 2/ 2 , . . �. , �-��. . �� C�ty o# 4rono euilding Permit Appiicatian for Maintenance 1 Replacement/ Remodel � R�sidential ONLY (i.e. windows, doors, sidinq, re-roof, etc, — NO STRUCTURAL EXPANSION) MaHing Address: � �-; / `�� ��0 PO Box 66 Permit number: / � l Crystal Bay, MN 55323-00�6 Date recefved� _� � - Street Address: ReCelved by� S ;� 2750 Kelley Parkway ' Plan revlew fee: � � � `�� w� Orono,MN 55356 'KFs ii oa ; 7otal Fee, `:��L•', (� � Main� 952-249�B00 Fax 952-249�4616 www.ci.orono.mn,.�.� This application form must be completed in full and af! required information must be submitted. fncomplete applications will be returned. (Please print) . . GEN�RAL 1NFORMATION; ��/ � Job Slte Address: ��[� �y,�r� rlace �rd��p /�/V ,�,53.� WiEI this be a Parade of Homes, Remdt(elers 5howcase Home or other Display Hame? Yes No !f yes,a specia!event permlt is n9qulivd w/th Polroe D6paltRtent&nd City Council approval 60 days prlor to the eve»t. ShuHle bus servi will be n9qulrelf un(Css applfC9nf demonshatos sutTicient on,site paiiring is avallable. Non-permitted evenfs wrff nof be allowed. CONTRACTOR/APPLIGANT INFQRMA714N: Name: 59 seo.,rn P�65 �ic~�r�arS State�.icense# (3�,�2 G�qQ�. Expir�tfon Date: y p Lead Certification Number: Expiration Date: (for work on homes thai wera canstructed prlor t�1978 � '� Phone; (cell) �3 �$� 2,��(� (office) �_..�.,_ ._.,..._,._ MailingAddreSs: ��-Ir.�-' 1C�r'�r`�'�r?__ . ��av � Cify: QSS�O ZIP: 5�'36� Contact Person: ��x Applicant is: Contractor / Homeowner (Circl�one) Em�il and/or Fax: ��,3 ��,�W � ��.�... ^ PR�PERTY OWNER tNFORMATION: Name: �, .�r Phone{day): /�..�9�3"�'O/ � Address: /c�s f�ne� v/eac� CitY� (7rar-�o ZIP' SS.�.�S�' Email and/pr Fax: „f� PROJECT INFORMATf�N: Overall ro"eet descri tion: "Typg of Project: Any earth mdvemant may also requlre ❑ Door(s) � Remodel ❑ Flre Damag� MCWD revlew&permlts: �Re-roof,asphalt ❑ Repair ❑Storm Damage Minneh2ha Creek Watershed Dlstr�c#(MCWq) 15320 Mfnnetonka�Ivd � Re-rooF,cedar ❑ Restoration ❑Water Damage . Minnetonka, MN 55345 ❑ Re-roof,oth�r(spaclry) Q Siding ❑ Other: (speclfy} Phone: 952-471-0590 Fax: 952-471-0682 ____ _. _... . ❑Window(s) www.minnehaha ce�9 � _.�.I Estimated Construction Valuation of ProJect(excluding land) � /�!�j(j� APPLICAN7'ACKNOWL�l7GEMENT: • Agrees to provide all Informatlon required or requested by the Building Depa�ment; • Certifies that the information supplied is true and correct to the best of h«lher knowledge. The applicant reCOgnizas that th�y are solely responsible Por submitting a complete applicatkon being aware that upon failure to do so, the staff has no altemstive but to reject it until it is complete; • Some or all of the information lhat you 2re asked to provide on this epplication Is classified by State law as either prlvate or confidential, Private data is informetian which general�y C�nnot be given to th� public but can be given to thB subject of the data. Confidential data ls Informatipn which generally cannot be given to either the public or the subject of the data. Our purpps�and intended use of this information is to annually update pur records and records o#other governmental agencf�s r�quired by iaw. If ou refuse to su i thp information' the a licatian ma not be issued. _._.._... _._..... �� Applicant's Signature� DatE: 5�.��6� Owner's Signature: �-- �ate� -��3��"�� Last Updated:Januery 2016 _ _.