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, . �i�y a� �ro�o ` � Buifding F'ermit A,ppii�a�io� for NEaintenance / f�eno�sa�ion (windows, doors, siding, re-�-oof, efc.) Marling Address: Permit number. �� - U�J �� j�v O,j�O PO Box 66 � � Crystal Bay, MN 55323-0066 Date received: ��a'OZ�–/ �� '�j�� s, i Street Address: Received by: � �'� ��`'�'l � 2750 Kelley Parkway o� Plan review fee: �'�kEsxo�� Orono, MN 55356 Total:Fee: �� , G,� Main: 352-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application forrn 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 E �y�„wcp� �� - Will this be a Parade of Homes, Remodelers Showcase Home or other Disp�ay Home? ❑ Yes ❑ No If yes,a special event permit is requrred with Police Department and City Counci!approval 60 days prior to the event. 5huttle bus service wil!be required unless applicant demonstrates sufficient on-site parkrng is available. Non-permitted events will not be aflowed. CONTRACTOR/APPLICANT INFORMATION: Name: �,��r ;u�,k �.-� 1-tr�.v,� �r i�� ` T' � State License# ..C-�� y,{� Expiration Qate: 3� 3 t - 1 Z Lead Certification Number: ��--, S6B�s f; - / Expiration Date: �_�� - � � (for work on homes thaf were constructed prior to 1978 Phone: _ _�� (office) (�j(�2-a�U - ��' (cell) Maifing Address: -�-� �f City: �� ZIP: Contact Person: �,�r Appiicant is: n / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: _�.�n:�� r �dc�� Phone (day): � s� .�.-�� -a� �� Address: City: ZIP: Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) � Remodel MCWD review&permits: ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) `� Re-roof, asphatt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑ Re-roof, cedar ❑ Restorafion ❑Water Qamage Deephaven, MN 55391 ' ❑ Re-roof, other s eci Phone: 952-471-0590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq Overall Project Description: 1 t�., - o,(,�' �,�„1 �� _ ,r�;,� Esfirnated Construction Valuation of Project(excfuding land) � � ''`� APPLICANT A�KNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; i • Certifies that the information supplied is true and correct to the best of his/her knowfedge. The applicant recognizes that they are solely responsible for submitfing a compfete appfication 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 ctassified by State law as either private or confidenfia�. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidenfial data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annualfy update our records and records of other governmental agencies re uired b taw. If vou refuse to su I the information,the a ficaf mav not be issued. AppiicanYs Signature: � — Qate: vZ `1 Last Updated: 08-09-2011