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�i�y of �ro�o � �� �` Buii�ing Permit Appi�catior� for M��ntenance / RenQvatio� � (windows, doors, siding, re-roof, etc.) Mailing Address j.� PO Box 66 i Permitnnumber. Crystal Bay, MN 55323-0066 i Date received: j ��"��,:»� � �a � �" �, Sfreet Address: Received by: � � �t�'�„_ �� 2750 Keliey Parkway Pian review fee: t`�gESH�''� Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This appfication form must be completed in full and all required information must be submitted. Incompiete appfications will be returned. (Please print) GENERAL INFORMATIOf�:�z�� Job Site Address: � �`"��'-��'�'� � Will this be a Parade of Nomes, Remodefers Showcase Home or other Display Home? ❑ Yes o lf yes, a specia/evenf permif is required with Po(ice Department and Crty Counci!approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates suffrcient on-site parking is available. Non-permitted events wil/not be allowed. CONTRACTOR/APPLICANT INFORMATIOI�: Name: ��ff.�n c. ��` f� r c-� State License # � , Expiration Date: Lead Certification Number: � ,4 Expiration Date: (for work on i�omes fhat were constructed prior to 1978 Phone: �..�Z . ��-�, �� (office) �.l�L G:,%.l�.s�� (cell) Maifing Address: � r�3 f'�� ,f- ,i� Cit : Y !� - "�-p Tr1-ZIP� „/"�z�' / Contact Person: C:-¢� - 2�J ` � � Appficant is: Contractor / omeown f (Circle One) Erriail and/or Fax: �Sr� �f � _s�Z� _�,��5 ., G�� - PROPERTY OWNER INFORMATION: y Name: C'.�t G.' ,' �.�- �?�<C� Phone(day): �� ( �� 3-;�� . Address: Z� (..� C ��'-v �T �D City: (,C��'�� ZIP: J�.1'�� Email and/or Fax ��"L � � , �-�� o ,, �x� _ ��{ �� C, %� PROJECT INFORMATION: Type of Projecfi ' Any earth movement may require I ❑ Door(s) ❑ Remodel ❑ Fire Damage � MCWD review&permits: Minnehaha Creek Watershed District(MCWD) �Re-roof, asphalt ❑ Repair ❑ Storm Damage � 18202 Minnetonka Bfvd I ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other s eci Phone: 952-471-Q590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � ❑ Window(s) I www.minnehahacreek.orq Overall Project Description: 3Z�� F- ��veRG' " ��2f�c.r- �;,��`� �-�: Estimated Construction Vafuation of Project (excfuding land) $ � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supp(ied is true and correct to the best of his/her knowledge. The appficant recognizes that they are solely responsible for submitting a complete applicafion being aware that upon failure to do so, the staff has 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 Stafe law as either private or �! confidential. 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 generally cannot be given to either the public or the subject of tne data. Our � purpose and intended use of this information is to annually update our records and records of other governmental agencies �_ required by law. If you refuse to suppl tne informafion the�npficaiion may not be issued � .� , ApplicanYs Signature: � C� �v`Z-��""y-''� /`'' �-�-� Date: '�-- /� �—.Jz-, �ast Updated: 08-09-2011