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OS-15-13;00:07AM;From:kuhl To:9522494616 ;9522588300 # 1 / 2 � Building Permit Appl�cat�on for IVlaintenance I Replacement ! Renovation (No strucfiural expansion. Only windows, daors, siding, re-roof, etc.) A, Ma!llrrg Address: Permit number: ��f vO Pp Box 66 Crystal Bay,MN 55323�0066 Dake received' a St�18t Address: Received by: F G� 2750 Kelley Parkway Pl�n review fee: r��srio��, Orono,MN 55356 Tota!Fee: Main: 952-249-4800 Fax: 952-249-4616 www-ci.orono.mn.us This application form must be compfeted in full and all required information must be submitted. Incomplete applications will be returned. (Please prrnt) GENERAI lNFORMATIOW: Job Site Address: ''��o =r;tr�C:h c;ai;:i=F< paiv� Will this be a Parade of Homes, Remodelers Showcase Home or other bOsplay Wome? Yes No If yes,a specre!event pemtit is requirmd with Palicv Department and Clty Councll approval 60 d�ys pnor ro tha event Shuttte bus sarvloe wlll be required un/ess appllr,�nt demonstratss suA7cfent on-site parking is evallabla. Non-permitted events wJ!!not be ello�ved. CpNTRACTOR/APPLICANT INFORMATION: Name: i<<;�i�_�; CCv�Fa,C7i�vG State License� [ic i�5�� Expiration date: �;i;,i�i;; Lead Certification Number: ��73a•i%z�o3� �xpiration Date: �ii i;�>��a (for wvrk on homes that were constructed pr►or to 1978 Phone: (cell)�i 2-�7�-��2s i (office)�52-��5-:��:�<; Mailing Address: >>75 souri-;5Ti-i sTF��r Gity: i io�i<in��s ZIP.:JJJ�.3 Gpntact Person; ToM K�RZEE�ER Applicant is: Contractor / Horneowner (ctrcioona� Email andlor Fax: STACIai��KIJH�DE51GNt3UIL.U.CC�N; PROPERTY OWNER INFORMATION: Name: sl-IARI DANI�LSOf�! Phone(day): Address: 125U �R�NCi l CI?EEK DRIvE City:WAY�A'1'A zIP;5,3��-�i0� Email andlor Fax: �ROJ�C7 INFORMA710N. overall ro ect descri tion: Type of Project: Any earth movement may also require ❑Door(s) ❑Remodel ❑Fire bamage �CWi�review&pertnits: i ❑Re-roof,asphalE ❑Repair ❑Storrn Damage Minnehaha Creek Watershed�istrid(MCWD) 18202 Minnetenka Blvd �Re-roof,cedar ❑Restoration 0 Wat�r pamage Qeephaven, MN 55391 ❑Re-roof,other(spoctfy) �Siding ❑Oth�r:(specity) Phone: 952�71-0590 Fax: 952-471-0682 ❑WindOw(5) www minn�hahacreek.orq Estimated Construction Valuation of Project(excluding land) $ ?�?%?�o APPLICANT ACKN�W��G�MENT: � Agreas to provide a11 inf�rmation required or requested by the Building Department; • CeRifies that the informaGon suppiied is true and comect to the best of his/her knowledge. The applicani recognizes that they are solely responsibie for submitting a wmplete application being aware that upon failure fo da so,the staff has no alternative but to rejEct it untfl it iS ComplEte; • Some or all of the infotrnation that you are asked to provide on this appliqtien is classifted by State law as either private or confidential. Private data is information whiCh generally cannat be given to the public but can be given to the subject of the data. Canfidential data is inforrna�ti0n which generalty cannot be ' n to either the public or the subject of the data. Our purpose and intended use of th' rma is to 2rfS�ll�.update rds and recerris o€other govemmental agencies required by law. lf ou refuse to s I the inform � n t�ie a ion not be�i55Ued. . Applicant's Signat re: Date: G'