|
Aug • 11 � 2012 6 ; 32RM it ' s a great day at bover bldg , No � 3280 P � 3
<br /> � �` �
<br /> ` CItyO� o�0�0
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re�roof, etc.)
<br /> Mailing Address: ' " "�"+" � " � � ,; � � 01�'��
<br /> —�: p [rri�it�aGmber �t�' rt '����� t
<br /> ��L,0,�.� P�O BOX BE r � �' � �,��'0r�� � � °�"� �
<br /> Crystal Bay MN 55323-0066 '�L1ate.r'rer�ecve`�i'"���i,; � :�' ` ,';� � ;
<br /> H,�y ����
<br /> � �� a. Street Add��ss: � ��c ued��b�y,j " �:1'"� �� � � �',�
<br /> �' 2750 Kelle Parkwa ��'�"�'i: " �P°`"� , �� � � '�� "r�G�
<br /> �+ � v Y Y 1�I��Osre��ewf�� , :�� ` � w ��e :s�
<br /> �'��sa��`'�' OronO MN 55356 s" �"`,�,��r�,A n �
<br /> , ��l��� � � ������, �4� ��„
<br /> � �Main: 952-2.49�600 Fax: 952-249-�616 Www.ci.orono.mn.us r������'� "� '�^"r^ � F� � � +
<br /> , ..K�6`�M ,, ... ,� r.��
<br /> ,.,.
<br /> This application form must be completed in fulf and all required information must be submitted.
<br /> Incomplete applications wifl be returned�� (Please prin()
<br /> .GENERAL INFORMA710N: �
<br /> Job Site Address: ��--��,S G'��',� `T'rL.P� �,C9�C a� �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home ar other D�splay Home? Yes � No
<br /> If yes, a special event permit is required wlth Police Oepartment and City Council approva!6o days prior to the evenf, Shuttle bus se ice will be
<br /> required unless appllcan!domonst,ates suf6cient on-srte parking is avallanlo. Norrpermitted events wi!l not be allowed.
<br /> CONTRACTOR/APP�ICANT INFORMA710N: �_
<br /> Name� Qo�Qr� 1��'��,�,SVvB'�. ue�Y��,�1"b1�
<br /> State License# (].�p��,��g' � Expiration Qate: � � �-j O r
<br /> Leaci Certification Number� �-T-�6z��'j���� Expiration Date� �
<br /> (fo�work on homes that were constrrrcted pnor to 9978
<br /> Phone: _ 5�-�-d�s� (offic�) ��—�3��S$ (cell)
<br /> - �' ���._ � __. _
<br /> Mailing Address• ���,s~ ���-� ��c � City: �� _ Z(P: ,�c{�,�
<br /> Contact Person; —j�pyy� /,,��`�,,�.y� � Applicant is� ontr c o / Homeowner (CircleOne)
<br /> Email and/or Fax� ���_ �-�5-`'����� �
<br /> PROPERI"Y OWNER INFORMATtON:
<br /> Name: ��YY�, � �S�u '��.��1�► ._._.�..__�
<br /> Phone (day)� ��- �'�,- � ay� ---
<br /> Address: �.`�� Si-+�er�3 ne� ,,..�.C,C,�r( City: p�y-p w ZIP_�-�c�I
<br /> Email and/or Fax
<br /> PROJECT fNFORMATION:
<br /> 7ype of Project Any earth movement may require
<br /> ❑ Door(s) ❑ Remodol ❑ Fire Damage
<br /> MCWD review&permits:
<br /> Minnehaha CI'eek Watershed District(MCWD) _
<br /> ❑Re-roof. asphalt U Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> Phone� 952-471-0590
<br /> ❑ Re-roof. othor(specity) � Slding ❑ Other (specify} Fax: 952-471-0682
<br /> ❑Window(s) r www.minnehahacreek.orp
<br /> Overalt Project Description: �e�� �l y�(�.Ql,�rS LL�y�Mi 1L ��
<br /> _ . . r�/,ms
<br /> �stimated Constrnction Vatuation of Project(ezcluding land► $ �'6�y��
<br /> � _. .w r ---�..,—
<br /> APPLICANT ACKNOWL�EDG�MENT:
<br /> • Agrees to provide all information required or requested by the E3uilding Depaftment; ' ^+ ~
<br /> • Certifies that the information supplied is true and correct to thcs best of his/her knowledge The applicant recognizes that they
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so the staff has no altemative
<br /> but to roject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this application is tlassified by State law as either private or
<br /> confidential. Private data is information which generally rannot be given to the public but can be given to the subject of the
<br /> data. Gonfidontial data is iniormation which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intendad use of tl�is information is to annually update our records and re�ords of other govornmontal agencies
<br /> re uired b law. If Xou refuse to s l the informaEion, the application may not be issued. _ m __ _ _
<br /> Appficant�s Signature� ~ _ ` ^ Date- .,c�`�7����
<br /> Las1 Updaled• D8-p9-2011
<br />
|