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City of Qrono <br /> Bui�ding Permit Application for Maintenance 1 Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Addriess: / _� <br /> �►0,� Permit number: � � <br /> PO Box 66 <br /> � �, � Crystal Bay, MN 55323-0068 Date received� <br /> � � . :`�-- ��� Street Addr�ss: Received by� <br /> ,��wG~ 2750 Kelley Parkway Plan reviewfee: <br /> 'tSEggp� Orono, MN 55356 <br /> Main: 952-249-0600 Fax: 952-249-4616 www.ci.orono mn us Toial Fee� �� -�j�I �'j <br /> �J �/ � <br /> This app�ication form musi be completed in full and al(req�ired information must be submitted. <br /> lncomplete applications will be returned. (Please printJ <br /> GENERAL INFORMATION: �1 <br /> Job Site Address: ql l� �j �(•�,,nC .�� . <br /> Wilt this be a Parade of Homes, Remodelers Showcase Home or other Dis pla y H o m e? Y e s N o <br /> /f y e s,a s p e c i a!e v e n t p e m r i t r s re quire d wi t h Pa lice Dgpartment and Cify Counci!approva160 days prior fo the event. ShuttJe bus seMce will be <br /> required unless applicant demonstraAes sufficient onsrte parking is availa6le. Non-permitted events will not be allowed. <br /> CONTRACTOR!APPLICANT INFORMATION: <br /> Narne: �.�, � ,A�trS.er� <br /> State License# ��,�'30c�$-3 Expiration Date: 'S(31 <br /> Lead Certification Number: �=� �a83 —1 Expiration Date: c{��s <br /> (for work on homes that were Consbvc(ed o�ir�r�0 197$ <br /> Phone: (as�— a _L�/o�'� (office) (ce!1) <br /> Mailing Address: � ap , � �• .� we�. Ci ��p: <br /> Contact Person: ty'�`��v�1�� SSI 3 <br /> _ Applicant is: ontractor / Homeowner (CirCleOne) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �� "��`1.. <br /> Phone (day): � f����� <br /> Address: �a _ �� Q <br /> Email and/or Fax - � C'ry� ZlP: <br /> PROJECT(NFORMATION: <br /> Type of Project: <br /> Any earth movement may require <br /> ❑ D�or(sj ❑Remodel ❑ Fire Damage M�D neview 8 permits: <br /> ❑ Re-roof,asphalt ❑ Re air Minnehaha Creek Watershed District(MCWD) <br /> P ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration Dee �aven, MN 55391 <br /> � Water Damage Ph ne: 952-471-0594 <br /> ❑ Re-roof, other(apecify� ❑Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑window(s) a Q�S www.minnehahacreek.ora <br /> Overall Project Description: OCX 5 �v� i S <br /> Estimated Construction Vafuation of Project(excluding land) $ Ytj� L� f � <br /> APPLICANT ACKNOWLEDGEMENT: 4 <br /> • Agrees to provide all information required or reyuested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowfedge. The applicant recognizes that they <br /> are solely respons'rble for submitting a complete application being aware that upon faiiure to do so, the staff has no altemative <br /> but to reject it until i1 is complete; <br /> • Some or a!I of the information that you are asked to provide on th'rs application is classified �y State law as either private or <br /> canfidentiai. Private data is information which generally cannot be given to the publiC but can be given to the suhject of the <br /> data. Confdential data is information which generally cannot be given to either the public or the subjecf pf the data. Our <br /> purpase and intended use of this information is to annually update our necords and records of other governrnental agencies <br /> re uired b law. If u refuse to su I the information,the a (ication may not be issued <br /> AnolicanYs Sionature: � �`T � <br /> G'�r�,'.`� Date: .7�J(JYLQ � <br /> Z 'd 06T9bL9TS9 3�IA213S lIW�l3d Q '8 S �I �� =�T ETOz SO ��C <br />