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To�. Paye 3 oT 3 Z0�4-03-20 '1�1:0'I:'10(GMT) From: Apex Ener'JY Solutlons
<br /> Gity of Qrono
<br /> Building Permit Application for Maintenance / Repiacement / Renovation
<br /> (No structural expansion. �nly windows, doors, siding, re-roof, etc.)
<br /> j%",�� �'� Mailing Address: permit number: o�� -�p�.
<br /> � ��\ PO Box 66
<br /> � � Crystal Bay, MN 55323-OQ66 Date received: � '" —
<br /> � �,
<br /> � ,, ! Streef Address: Received by:
<br /> �'. 1 `% 2750 Kelley Parkway Pfan review fee:
<br /> �`��q a`�'1� t.`' ' Orono, MN 55356 � �
<br /> �FSHVF,� Total Fee: ��� �O
<br /> Main: 952-249-4600 Fax: 952-249-4616 v�n,;�ci.orono.r�;7.us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please prrnt)
<br /> GENERAL tNFORMATION• �1 ..�-
<br /> Job Site Address: ��t-f � S'�-�nc�{G��'e-,
<br /> WiH this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No
<br /> If yes,a special event permit is requimd with Police Department and City Council approval 60 days prior to the event. Shuttle bus service Unll be
<br /> required unless applicant demonstrates su�cienf on-site parking rs availabJe. Non-permitted events wiN not be allowed.
<br /> CONTRACTOR!APPLICANT INFORMATION:
<br /> Name: �1-Fu-x �i���Gi t,� ..s�f�i�`rL,S
<br /> State License# ��r����(,}.� �� �'x��¢>� Expiration Date: ---
<br /> Lead Certification IVumber: /.!f}T' - �j ��i 3�-1_. Expiration Date� yn�,,.T t� ��t�
<br /> (for work on homes that were constructed prior fo 1978 �—
<br /> Phone: (cel�) /�,Si -SG�� --��/ :3`i (affice)
<br /> MailingAddress: ,�'�fpU /�lr��'m4��:Zccl� c �j1V� Sui'� �f,2;; City ,,,�'3Jo,;rr�i�y�'f�'�- Z1P� �ti,:37
<br /> Contaet Person: ��zY-�{ (ic J��r- Applicant is: Contractor / Homeowner (CirdeOnej
<br /> Emai!and/or Fax: C��tE'�()�v`�C i�rti3�� ���t'r}
<br /> _. � �___._._____._._.__.
<br /> PROPERTY OWIVER INFORMATIOIV:
<br /> Name: f CR h'� .Si2-f�Y'
<br /> ( Y)= 1� �:3S'L^"_��`�__�_ ,
<br /> Phone da ��
<br /> Address: G' C� \!�) �f c+r"f'�G�QM� � ��'tY= (�"�L�C ZIP: "J`�J.�f�
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Overall project description:
<br /> - ._
<br /> Type of Project: Any earth movement may also require
<br /> ❑Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits:
<br /> ❑ Re-roof,asphalt ❑Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWDj
<br /> 18202 Minnetanka Blvd
<br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage � Deephaven,MN 55391
<br /> ❑Re-roof,other(specify) ❑Siding ❑ Other(specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> [�Window(s) , wwed minnehal�a�reek orr,
<br /> Estimated Construction Valuation of Project(excluding land} $ _:,,�3� c�, '�,Gt�
<br /> APPLICANT AGKNOWLEDGEMENT:
<br /> __...
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the informa8on supplied is true and correc:t to the best of hisJher knowledge. The applicant recognizes that they are ;
<br /> solely responsible for submitting a complete application being aware that upon faiture to do so,the staff has no alternative but to �
<br /> reject it until it is complete; �
<br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or �
<br /> confidentiaf. Private data is information which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidentia(data is information which generally cannot be given to either the public or the subject of the data. Our purpose and i
<br /> intended use of this information is to annually update our records and records of other govemmental agencies required by law. ff
<br /> ou refuse to su pl he informati the a n ma not be issued.
<br /> ,, , � ;: , - �7
<br /> ApplicanYs Signat�r'e:,- .."<, '_.:�. `- ��::,� , r -' / -----�.,�__ �ate: , r�. J,
<br /> �....�.,_ `
<br /> /_
<br /> Owner's Signature� Date:
<br /> Last Updated:03J06l2013
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