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01-30-'15 10;27 F�OM-purpose driven restr +763-633-9751 T-939 P0002/0002 F-111 <br /> � r <br /> City af (arono <br /> Building Permit Application for 11Aaintenance / Replacement / Remodel <br /> (i.�. windows, doQrs, siding, re-roof, etc. — NO STRUCTURAL �XPANSION) <br /> ,���TO Mailing Addre�s.� P�rmit number: . Q / <br /> �{� PO Box 68 <br /> Crystal eay, MN 55323-0066 Dabe received: �—���/ <br /> Strsel Address: Received by: <br /> � � 2750 Kelley Parkway Plan review �: <br /> `nl G Orono,MN 55356 <br /> qKFst(0�� Tot81�ee: ���• p� ! <br /> M�in: 952-249-4800 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplet�applications will be returned. (Please print) <br /> GEN�RAL INFORMATION: -7 ;^� <br /> Job Site Address: ���( �vc�L'l�1GG'� •�o�r�" � _ <br /> Will this be a Parade of Homes, Remo�t' elers Showcase Home or other Oi$play liome? Yes No <br /> If y�s,a specla!�vpnt pBrmit is required wdh Police Department and C/ty CounGl approVa/80 days prior to the ewent, Shuftle bus service wll/be <br /> �qulr�tl un/oss appliCant d�monstrates su/ficrent o»�Aa parking is ava�labfG. Non-permitted evenis wiN not be allowed. <br /> CONTRAC70R/APPLICA T INFORMATIO : <br /> Name: ��,L �,�y� ���io�'� <br /> State License# � Expiration Date� ?� �'j� �p(�j� <br /> Lead Certification Number: �-`�9a Q�.� ExpiraEion Date: ���� •�p�� <br /> (for work on homas that wors construct�d prlor to 1978 <br /> Phone' (cell) f2- �}����}� (o�c6) ��'�-�;���y 7J 7 <br /> Mailirtg Address: ��rj" ;� �j(- (� City:�tl� y'�" ZIP: �"'j'�;3:�Q <br /> ContaCf Person: p�y,n �,n Applicant is: Con ractor / Homeowner (c��c�o ons► <br /> Emailand/orFax: ��,� ttiw�.(�,��,n o�- �-l03�-�'7�1 <br /> PROPERTY OWNER INFORMATION: � _�� <br /> Name: ��� c�C �a'�i �.�.►+nc�c�v��' <br /> Phone (day): ., ��� (���j- g '� <br /> Address 3'j e�,�c�-, „r, City:�Cov�c> ZIP: ������ <br /> Email and/or Fax: ` <br /> PROJECT INFORMATIQN: Overall ro�ect dsscri tion:� ' ' i fi�7�,"�c�e � �:`�1.d�, 11�ri�i'�j�' <br /> Type of Project: Any�arth movement' ay also require � <br /> ❑ Door(s) ❑ Ftemodel ❑ Fire Damaga MCWD r@vi�w S,permits: ' <br /> Q Re-roof,asphaft ❑ Repair [,�Storm Damag� Minnehaha Creek Wat�rsh�d District(MCWD) <br /> 98202 Minnetonka Blvd <br /> � Re-roof,cedar ❑ Restoration �Wat�r Damage Deephaven,MN 55391 <br /> � A �) � g ❑ ( p �) Phone: 952�71-0590 <br /> ❑ Re-roof,other s eci Sidin Other s aci Fax: 952-471-0682 <br /> �Windaw(s) www.minnehahacreek.orq <br /> Estimated Construction Valu�tion of Project(excluding land) $1'7,OUC>.�0 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> £� Agr�es to provide all infomiation required or requested by the Building Depsrtmeni; <br /> f� Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> svlely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is oomplefe; <br /> �1 Some or all of the informaSion that you are asked to provide on this application is classified by State law as either privat� or <br /> confideniial. Private data is information which generally Gannot be giv�n fo tho public but can be given to ths subjecf of the data. <br /> Gonfidential data is information which generally cannot be given to either the public or th�subject of the daCa. Our purpose and <br /> intended use of this intormation is to annually update our records and records of other governmental agencies required by law. If <br /> ou rafusa to su I the infonnatio th fication ma not be issued. <br /> AppliCanYs Signature: d�v� � �� bate: � �✓0 1J� .. _ <br /> Owner's Signature: Date: <br /> Last Updat6d=J�nuay 2015 <br />