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1 1 Sent using FaxBurner.com �Il� VI VI V� IV Buitding Permit App�ication far Maintenance 1 Replace�n�nt ! Remodel �i.e. windows, doors, s+ding, re-roof, etc. — N� S�R�JCTURAL EXPAh�S10Ny � Marlrn�Address: Permit�umher: �� � �� PO Box 88 � Crystal Bay,MN 55323-dOfi ��I Date received: ��-�� � Stree�Address: � S�eCeived by: 'i�, G� 2750 Kelley Pdrkvuay ��/ Plan review fee; �,� �. Or3no, MN 55356 � /! /_ ke$'��R 7otal Fee: �� J Mai�: 952-249-4600 Fax: 9§2-24g-46t6 www.ai.orono.mn.us This applic�tion form mvst be GOmpEeted in full and a!I required inforination rnust be subm�tted. Incomplete app11ca11ons wlll be returned, {Please pr�ntj GEh1�RA�INFOAMATION: dob Site Add ress: ��oc� �T�r�'L ��v II. (�J/�Y�/f%�. Nt�✓ -j-r 3`t/ WIII this ae a Parade oi Homesr Remodeters ST�nwcase FEpme or other I] spl�y Home? Yes �No J/yes,a specral evertf pe�mii is required witt:Police Departme�l and Cify Coun�if appmva�60 days prr'or fo fhe etre�f. 5huttre bus Se»�iCe wi!!be re+gbired unfess ep�ficant dpmon5lr�tes suffi'clenf an-s;t�parKing i5 av�i12b78, NPn-perm;t�ed events wiU rtdt be��rowed CONTRACTQR tAPPLICA�iT lNF�RMATION: Name: _..:T'�rM G+'-n�.P R.oncrn�G Siaie License#f ��7Jr� �xp�ralion Date: p3 -�/ � _��t ,� Lead Certification Number: ��71 3 �j Expiration Datc: !2 -3� -2r�r � (for wOrk on homes ihat were cnnstructed prior to 19T8 Phone: (ce11} �'j2 -,S',�� _ ��.-�� [offce) `� � -- Mail�ng Address: 73v8 ��A�✓ L�n� r✓ �viT� iJ�' CitY�lS�`�o.rcv,y P.�.eI:. 2�P:�S.S 2 �s� Contact Persan: p„�rr�r Lit�Hr,tr F Applicant is: Cortractor 1 Homeowrner Scv�iBor,e� Email andlor Fax: ��r�o�rr�ar,�Qo�P�po�i�r. <�� PRC3PERTY OWNER INFORMATIOh: h�ame: �,eisfin,r,4 ,�cttr�GT2 Phone(day}: �1Z —�6D � �S 7�� Address: 2?ac� �Tfr•r� RLrrpr Lv�-r��r� City: �.-A�-µ,�-r� Z1P: S�3 `�j EmailandlorFax: };� Ptf2SpM�„�c,M • PROJECT INFQRMATIQhl: Querall ro'ect descri tion: Type o}Pro�ect: Any earth mbvement may also require , " MCWb revEew 8 permlts: ❑ Door,$) ❑Remodel ❑Fire Qamage Minnehaha Creek Watershed District MCWD g Re-�oof,asphalt ❑Repa�r . ❑Siorm aamage iB20�Minnetonka Blvd { } ❑ f2e-roof,ceda� ❑Restora:ion ❑Water Damage Deephaven.MN 55391 E] Re-roof,olher{apecify� ❑8iding ❑Qthec(speci�,r} Phane: 952-A71-0594 Fax: 952.471-068 2 �Window(s} wwtiv m?nnehahacreek.or �st[mated Constructlo�Valuaiion of Protect(excluding land] S o0 APPLIGANT ACKNOWLEDGEM�NT: . Agrees ta prcvide all information requn-ect or requested hy the Build ng Depar.ment; • Certif�es that the informsGon supplied is tnae and correcl to the r��st of hislher know!edge. The applicant recocnizes that they are solely respons'bfc for submiit�ng a complete application being aware tY:aS upon fal,uee to do so,the sia[i has no alterr.afive but to reject it untfl�t is�rnplete; • Some or afE of the informalion thal you $re asked to provide on this app'Icat;fln is classified by State law as either private or confidential. firiva!e data is information which genera!ly cannot be given te the p:�b;ic b:,t can be given to the subjecE of the data. Conf;dantia!data is i�torr�at�on which generafly Canrot be gl�en to either the p�blie or the subject of the�ata. Our purpnse and intended use of this information is to annually update aur reoards and records a!other govemmental agencies requ;rcd by lew_ if u re+use lo sv I the irrfo ation the a lication m�t not be issLed. I �PAlicant's Signat�re: ._^..T_ pate: .�-/�a�rr�.S~ I Owner's Signai�re; __ _ Date: �.