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Ci�y of Urono <br /> Building Permit Application for Maintenance I R�novafion <br /> (windows, daors, siding, re,roof, ertc,) � <br /> M�Iling Addr�ss: Permtt number: �� � —�� <br /> Q,�Q A ti� PO Bax 66 / _ <br /> `r Crystal Bay,MN 553Z3-0066 [3ate received: — � �� <br /> ,� �- �, StreetAddness: Recelved by: <br /> � � � . � 2750 KeEley Parkway Plan review fee: <br /> � �.° Orona,MN 55356 � , / �� a� <br /> Total�se: �f / <br /> Main: 952-2a9�60D Fax: 952-249-4616 www.ei orono.rilt�.us <br /> This�pplication form must be corr►pleted in fiufl and all required infnrm$#ion must be br'rritted_ <br /> lncomplete app4icatlans wltl be returned. (Please prrnt) <br /> GEPI�RAL INFORMATION: ���Y� �Q� � <br /> Job Site Address: � <br /> Wilf thls be� Parade of Horrtes, R�emodelers Showcase Home or other D1spl�y Home? Yes No <br /> {f ye5,a specle/event permi�is roqulred with�'o1loe Department and CIfY Counc!!app�ova!BO days p�or tn ihe e+rent. Shuttle bus ssrvice+vil1 be <br /> required unleas applicant dBmonsfrafe8 sufficfent on�site p6�fdn8 is avd!!able. Plon-permitt9d events w!!/not 8e&llowed. <br /> C�NTRACTOR f APPUCANT INFORMATtON: <br /> Name: 'C r��a.\ ���'��-'N <br /> Stete Llcensa# C„\'309 3 �xpirat�on Date: 3 j 3 <br /> Lead Certificatlon Number: �j�'�-- ��'�-�`�'� �1 �xpiratlan Date: �( <br /> (for wur�c on homes d�at vvere canstructed prior t+�'f978 n E�ejj) <br /> Phone: (n51� �(p -'y 0 S�d' �t�qn (office} <br /> M$iling Address: 19 C. ••G•• l�j�Sk CitY: �1 � �1P: SS I <br /> Contact Person: App[iCailt is: ntra / Homeowner (Cir¢!4 4ns) <br /> Email and/or Fax: <br /> P�tOPERTY OWNER lN� MATION: <br /> Name: E ' ( ��� , <br /> Phone(day): <br /> Address: City: ZIP: <br /> �mail and/or Fax <br /> F�ROJECT 1N�O�tMATION: <br /> TyP��Prol��: Any earth movement m�y rec{uire <br /> MCWD revlew�permits: <br /> � p�r�$� [� Remode€ []Fine Damage Minnehaha Creek Watershed I�istricf(MCWD) <br /> ❑FZe-roof,agphalt �] Repair ❑Sto»r Damage 1$2(l2 Minn�ionlc�Bivd <br /> E]eephaven, MN 55391 <br /> � []R�roof,cedar ❑ Restoratian �Wat�r Damage phpne: 952-479-0590 <br /> �Ra�roof,othQr(spectfy} ❑Slding ❑Other. (specify) Fax: 952-471-0682 <br /> www,minn ehqh ecresk.or�c <br /> []Window(s) <br /> Ov�era#I Pro e�t Description: � � <br /> Es#imated Cpnstruction Valuatlon Pro ect(excludin `land) $ . � <br /> APPLiCAN7 ACKNOW�EDGEMENT: <br /> . ,q�rees to pt'ovide ail tnformation r9equired or requested by the Building Departm�nt; <br /> • Certt�es that the inforrnation supplied is true and oorreCt to the best af hisJher knoWledge. The appl€csnt r�rcOgnizes that they <br /> are splely responsible for submitting a complet� application being awa�'e that upon failure to do so, fhe staff has no altemative <br /> but to reject it until It is complete; <br /> • Same or all of the Information that you are asked to provlde on thts applicat3on is clsssified by Sfate iaw as either ptivate or ' <br /> confidantEai. Private date�3 is tnformation which generaliy cannot l�e given to the public but Can be given fo the subjecf of fhs <br /> data. COnflderstial data is in�formaUvn whlch generalfy cannot be gEven to either#he public or the subf ect of the data. Our <br /> purpose and intended use of ihls informadon is'� ennually update our r�cor'ds and recards of ofher govemmenta! agencles <br /> re uired b law. If ref�.rse to su 1 the(nform�tion,the a lication ma not be issued. <br /> Aflolicarrt's Siansture: pt� � Date: �� <br /> ������ <br />