Laserfiche WebLink
�� <br /> ■ 1Vl�l/�' ` � <br /> City of Qrona � ����ti�ti�,�' <br /> �uilding Permit Application for Maintenance / Repiacement/ Renovation <br /> (No structural expansivn. �nl windows, doors, sfdin , re-raaf, etc.) <br /> .��,.� n�ari;ng ada,�ss: �� ; � <br /> Fmi�:nur�beF <br /> PO Box 66 �' . � ��- <br /> Crystal Bay,MN 55323-0p66 Dat�e reyeived., , ,: <br /> St�et Address: RBc�n+�d by . <br /> �'.� '� 2790 Kelfey Parkway , ' ' <br /> v Plan revig'wfee: <br /> l�r� s��g.� Orono, MN 5535B <br /> Main: 552-249-0600 F&X: 952-249-46i8 Totai Fee• . �,� /ytAcG <br /> �eoe(,�f_orono.mn.us Cf C,� , �� �''P <br /> This appllcation form must be completed in full and all requlred infiormat�on must be submiited. <br /> Incomplete applicatlons witl be retumad. (Please print) <br /> GEN�RAL INFORMATION: � � ` <br /> JobSiteAddress: � rj�l �OX �T(�.�.� <br /> Will ttiis be a Par*d�of Hames, Remode[er�Showca�e Home or other Display Horr�e? Yes No <br /> h yes,a apedel ev�nt pennit is repu/r�d w/th police Depertment arrd Clty Gbund!approva!60 days priw to the event Shuttle bus servlce wrll be <br /> �BGuIJ�d unlesg applicant demonstrahsg 3uA�cient pn-si{a pa�dnQ is avallab/e, IVon�perntrYted event�Will not be aIlowed. <br /> CONTRACTOR/APPLICANT INFQRMAT[pN: <br /> Name: �3o,c,k�;x �. 5 w�e.c s �� 1 s� C1y,d:�.�. G1�;m n Com an <br /> State License� � Expiration ate: <br /> �ead Certification Number: �j�q�� „ � Expira#ion Date: <br /> (}4or rvork on homea bhat woere constructed prlor tio 197"8 -- �.� <br /> Phone: (cell) (o�ce) �fo 3 - �3�..(0113 <br /> Mailing Address; } - ti 4� A�, ns. �. City: �,r��,�,� ziP: 55 30 <br /> Contact Person� Appllc�nt is: Contractor / Nameowner <br /> �mail and/or Fax: 1����g one� <br /> PI�OPERTY OWN�R INFORMATION: <br /> N�me: ���5 l.U� 'C�'� ae Sf�( <br /> Phone(day): a�y — 3 <br /> Add ress: c�,; CitY= ZI P. <br /> Email and/or Fax; <br /> PROJECT(NFORMATION: Overa�l rp•ect descri tion: <br /> Type of Project: <br /> Any earth movemen!m�y also requlr� <br /> ❑Door(s) ❑Remodei MCWD review 8 <br /> ❑Fine damage permlt9: <br /> ❑ Rc-roof,asphait ❑Rapair C]Stamt�amage Minnehaha Cr�ek Watershed l�istriet(MCWD) <br /> ❑Re-roof,cedar ❑Restoratlon ❑Wa{er pame e �$z02 Mlnnetonka Blvd <br /> 9 Deephaven,MN 55391 <br /> ❑Re-roof,other(spee�fy) ❑Siding ❑pthg�-�gp��� Phone: 852-471-0590 <br /> I]v�ndow�s��`G1•�t �t�s�,rna� .t�1�.�nrt Fax: 952-471-0662 <br /> �- www � nehah ek_o <br /> Estimated Canstruction Valua�ion of proJeot(�xcluding iand) $ <br /> �PPLECANT ACKNQWLEDGEMEN7: <br /> • Agrees to provide all informabon requir+ed or requested by the Building DepartmerYt; <br /> • Certifles thaf the Informatlon supplled is true and corr�ct to the best of hls/her knowledge. The applicant recogn{zes that they are <br /> solely responsible fnr gubmifting a complete epplication befng aware that upon failure to do so, the staif has no aftemati�e but to <br /> reject it untf)it ie com�lete; <br /> • Some or all af the iMorrn�tlon th�t you ar�e asked to provide ort this appllcation is Gass'�ied by State Iaw as either private or <br /> confldential. Private dsta is iriformation which generalfy cannot be glven to the public but c�n be glven to the aubJect of the data. <br /> Confldentiel dat� is information which generally c�nnot be glven to efEher the pubfic or the subject of fhe data. Our purpose and <br /> Intended use of this informatl�rt is to anrrually upd2tie our records�nd records of other gpvemmental agencies requiret!by law. If <br /> ou refuse to su I the informatian the a lic�tion m� not be issu�d. <br /> �pplicanYs Signature: pate: 1�] <br /> ��I�Ea�y�-1�-(oto <br /> �wners Signature: p��: <br /> -ast Updat,�d:03/06l2Q13 <br />