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� 2 J�,i , . '� ' ��'��,N"�� : � �. ��r m� r� I a.1 1'�o, U�3 7 P, 1 � �It�' O'� �1'O�O Building Permit Appticafiion for Maintena�ce / Replacemenfi / Renovation (N� structural expansion. dnly windows, doors, siding, re-roof, etc.) Mailing Address: Permit n�nnber: �� PO Box 66 � Crystal Bay, MN 55323-0066�� Date recefved� StreetAddt�ss: Received by: d•k "�`� �SS�.O ,f2 � Z' 2750 Kelle Parkwa (i�' "5��, � Y Y � Plan review fee: 1,�K�Sxo��' Orono, MN 55356 /� �� Total Fee' Main: 952-249�600 Fax: �J52-249-4616 www.ci.orono.n�r�u� 7his appficafion form must be compl�ted in full and all required information must he submitted. Incomplete applications witl be refurned. (Please printJ GENERAL INFORMATION: Job Site Address: a�y� �r�n �f� ��,1��-- /�o�� WIII thls be a Parade of Homes,Remodelers Showcase Home or other bisplay Ho►ne? Yes No !f yes,a spec/al event pemiit is requirec!with Polrce Department and C�Ey Councll ap�rova160 days prior to the evenl. Shuttle bus ser✓iCB wl/l bo requ�r�d unless a��llcant demonslrates sufficient on-site pArking is availab�B. Non-permllfod events wlll nof he e/fowecl. CONTRACTOR!ApPLICANT IN�OI�MATION: I Name: Se. ..- �orr+m{rc.�"c�/ � 'V• � � _ ` State License# �� dd �� r Expiration Date: �� S ' Lead Certification Number� N,�-�_ �y63 y� � Expiration Date: �� / �. � (for work on homes that wo�consfructed prlor to 1978 � f ' Phone: (cell) (office) � ��{ _ �„ a�_ /� g`� Mailing Address: J�� G�� , F City; � r Lz11'� S Contact person: )�� Applicant i : ontracfor Homeowner (Clrcle0ne) Email and/or Fax� ,� �,��;s�:�G�s�S��2oa�,-,.� , a r7 _ PROP�IZTY OWNER 1NF�RMATION: Name: _S�ti�G. IL�a „��ri rr � Phone(day): 9�ya - y 7 3 - 4.�i `77 Address: ��ty� �r<,.�,h Ldc!-�� L�� CitY v (onu ZIP: ,�r.'s 3 S,� Email and/or Fax: PROJECT INFORMAT[ON: �verall ro'ect descri tion: `� r �� t - oa �c �, � Sr�. -S c� 7ype af ProJe�t: Any earth movement may alsa require ❑ Door(s) ❑ Ramodel ❑ Fire Damage MCWD review&permlts: ❑Re-roof, asphalt 0 Repair ❑ Storm pamage Mlnnehaha Creek Watershed District(MCWD) 18202 MinnetonKa Blvd ❑ Re-roof,cedar [r Resforation ❑Water bamage peephaven, MN 55391 �c Re-roof, other(specify) ❑5iding ❑Other:(specify) Phone: 952-471-0590 `�" Fax� 952-471-0�82 fpOM ❑Window(s) www.minnehahacreek.orq Estlmated Construction Valuation of Project texcluding land) $_,g, 7 04 ,00 APPLICANT ACKNOWLEDGEMENT: . Agrees to provide a0 information required or requested by the Huildinc�Department; . Certifies that the informafion supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application befnc�aware t1�at upon f�ailure to do so, the staff has no alternative I�ut to reject it until it is complets; • Some or alf of the InFormation that you ere asked to provide on Ihis application Is classiFied hy State law as either private or contidenflal. Private dat�is infonnation which generalty cannot be given to the pub6c but can be given to the subject of the data. Confidential data is information which ganerally cannot be c�iven to either the public or fhe subjoct of the data Our purpose and intended use of this information is to annually update aur recortls and records of other governmental ac�encles��equired by law, If ou refuse ta su I the informatlon,the a lieation ma not be issued. ApplicanYs Signature: 2� Date: � .2 � Owner's Signature: Date� L,asl Updafed�03/06/2013