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+ �� y ��a�e �� Gity of Qrono Buitding Permit Application for lViaintenance / Replacement / Renovatian {No structural expansion. {Jnly windaws, doors, siding, re-roof, etc.) _— ` ��`- MailnTg Address: Permit number: �3 -Qd � � � ' V�� PO Box 66 — `�s C stal Bay, MN 55323-0066 Date received: 5-� �� � J `' � !` Street Address: Received by: __________ l. � � �/ 2750 Kelley Parkway Pian review fee: `' � Orono, MN 55356 1, ,\ !^ih E�,��/ - Total Fee:iv�� 8 3, � �.._� . Main: 952-249-4600 Fax 952-249-46�6 y�,�ry�;_=,;,i_Cron��rnn��s / This application for must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: �Q�Q �t(`(� �/ �(!� � Qrbii/Q Will this be a Parade of Homes, Remodelsrs howcase Home or other Display Home? ❑Yes No If yes.a special event permii is required with Police Department and City Counci!approva!60 days prior to the event. Shutlle bus service wrtl be required unless applicant demonstrates sufircient o»-sife parking is available. Non-pen»rtted events wiH not be alJowed. CONTRACTOR 1 APPLICAN7 INFQRMATIt�N: Name: �'SE �" pr�j State License# � Expiration Date: ,� ( Lead Certification Number: � ._ Expiration Date: � j�- Q (foi work on homes thaf were constructed prior to 1978 Phone: (cell) ( 3$g' $�;"" (office) / `3s'�'-= � Maiiing Address: L( �l��` j� City: ZIP: f� Contact Person: �'( �� Applicant is: Contract / Homeowner �ci«�eo�e> Email andlor Fax: �1�.�r ��jts" ��j��p PROPERTY(3WNER I RWIATION: 6��' '��t+� ��/�`'�� d�..� Name: e7C �� c/ �T "� Q�. Phone(day): - s' .- Address: City� ZIP: Email and/or Fax: PROJECT INFORMATION: Ouerall ro�ect description: i Type of Project: Any earth movement may also require ( ❑Door(s} ❑Remodel ❑ Fire Damage MCWD review&permits: l�Re-roof,asphalt ❑Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 18202.Minnetonka Blvd� � ❑Re-roof,cedar ❑ Restaration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof,other(specify) ❑Siding ❑Other: (specify) ,.-- Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(S) y�nvtiv_rni_}r�ehahacreek.o_q Estimated Construction Valuation of Project(excluding land) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplietl is true and correct to the best of hislher knowledge. The applicant recognizes that they are solefy responsible for submitting a complete application being aware that upon failure to do so, the staff tras no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidentiaf. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which gener I!y nnot be given to either the public or the subject of the data. Qur purpose and intended use of this inf mation i to a a�l date aur rF:cords and records of other governmental agencies required by law. If ou refuse to su f t inf m n i fon may not be issued. Applicant's Signature: Date: ��I�� Owner's Signature: Date: Last Update.d:03ld6l2013 _ . _ _