Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
� � City of �rc�no <br /> Building P�rmit Application for Mainten�nce / RenovatiQn <br /> (windows, doors, sid�ng, re-roof, etc.) <br /> MailingAddrgss' Permit number: � �y�b�� � <br /> ����Q CrystaXBay, MN 55323-0086 Date r'eCelvsd: -'�5^ <br /> Received by: <br /> � ,, Street Address: <br /> � ' � � 2750 Kelley Paricway Plan review fee: <br /> ���� Orono, MN b535B <br /> Total Fee: ��� . I(� <br /> Maln: 952-248-�4600 Fax: 852-249�616 .ci.o mn.us <br /> 7his application farm must be complefed 'sn full and ai!required Informatian must be submitted. <br /> lncompEete applicat{ons wfll be returned. (Please print) <br /> GEN�RAL iNFORMIA,TION: �y� ��� <br /> Job Sfte Address: • ' <br /> Wil!thls be a Parade of Homes, Remadelers Showcase Wom�or other Display Home? ❑Yes No <br /> lf yea,a speciaJ evenf permft 19 requir�d wlth Police D9pa►tmenf and City Councif approva160 deys pnor fo fhe avent. Shu�e bus servlce wilf be <br /> requlred unless applicant demonstrstes sui�icier?f on�ite parking is av&lla6le. Nbn-permitte�d events wl!!not be allOwed. <br /> COWTRAGTOR/APPLICANT IN�ORMATION: <br /> Name: i�. \ ��{-'��� <br /> State License# '$G1�09 Expiration Date: 3 f 3 <br /> Lead Certlflcation Number: �j�'j'.- ��a$3 - Exp{ration Date: �( <br /> (for wnrk o�r homes that were constructed prior to 1978� (Cekl) <br /> Phone: (o�J�� o� -�0�' ,�q (oftice) <br /> Mailing Address� 1 � _ "� �• �• UJeS-'r C�tY'�C �11� ZIP: SS 1 3 <br /> Contact Person: Applicant is: on or / Homeowner �c��+a ona� <br /> Email and/ar Fax: <br /> PROPERTY O'WNER{f�FORMA710N: <br /> Name� �',�n., `���- 0.�'�n � <br /> Phone (day): �1`'SZ-- (D _ C��: ZfP: <br /> Address: ^ <br /> Email�nd/or Fax M <br /> PFtpJECT INFOi�MATION: <br /> Type of Froject: My earth movement m�l require <br /> IVICWD revfew&permits: <br /> � Door(s) ❑Remode! ❑ Fira Damaga Mlnnehaha Creek Watershed bistrlct(MCWD) <br /> ❑Fte-rpof,asphalt ❑I�epair ❑Starm Damage 18202 Mlnnetonka Blvd <br /> Deaphaven, MN 55391 <br /> � Re-roof,cedar ❑ Res#o�'dtlon ❑Water Damage Phone= 952�7�-0590 <br /> [�Re-roof,other(specsfy) 0 Sfding �Other:(specify) �ax: 952�71-0682 <br /> www.minnehahacrEek.o�r <br /> ❑1Mndow(s) <br /> Overafi Pro sct Description: "Pz �aG¢ �3 �i �-�b �or"r S C.�I:'^ :Sf' Q � <br /> Estimated Construction Valuatlon of ProJect(exctudin land $ $ �S <br /> APPLICANT ACKN4WLEDGEMENT: <br /> . Agrees to provlde ail information required or requested by the Building Depa�tment; <br /> . Certifies th�t the informatlon supplled is We and correct to the best of hls/tier knowledge. 7he applicant recognizes that they <br /> ere s�lely responsibfe for Submitting a complete apptication being aware that upon failure to do So, the staff has rto altemative <br /> but to reject it untll It is Complete; � <br /> . Some dr alf of the Information thaf you are asked to provlde on th(s appEicabon is classfied by State Iaw as either private or <br /> confidentlal. P�ivate data 1s informat;an whiCh gen�rally cannat be giv�n to the publla but can be g�ven to the 5ubject of the <br /> data. Confid�ntlal data �g �ninrmatlon which generelly cannot be given to either the pLlbflc or th6 subjoCt af the data. Our <br /> purpose and intended use of this informaUon ls tv annually update our records 8nd recorcis of other govemmental agencias <br /> re uired b lsw. tf au refuse to su 1 the information the a lication me not be issu�d. <br /> Date� ���U�`;�'�d <br /> At�olicanYs Sian�fi.ire: � (f <br />