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► <br /> City of 4rono <br /> Building Permit Application far Maintenance/ Replacement/ Remodel <br /> (i�e. windows, doors, siding, re-roaf, etc. -� NO STRUCTURAL �XPANSION) <br /> Mailing Address.� Permit number. ZO l S ^ (�V Z.. <br /> �—Q�IO PO Box 66 <br /> Crystal 8ay,MN 55323-0066 Date received: '' 4—�S <br /> StreetAddress: Received by, �� <br /> y� ti 2750 Kelley Parkway Plan review fee: �� <br /> `�� �`� Orono,MN 5535fi � p . Q� <br /> "�KE�SH��' Total Fea: � � <br /> Main: 952-249�600 Fax: 952-249-4516 www.ci.ofoil4,mn.us <br /> This applic2tion form must be completed in full and all requir�d information mu be su mitkQd��. � <br /> Incomple�te applicetions will be returned. (Please prinf) ���� / -� <br /> GENERAL INFORMATION: � +, �f�� m � ���� I �l�/ J <br /> Job Site Address: (� ' Cf' (�G � <br /> Will thls be 8 Parade of Homes,Remodeler,s ShowCase Home or other Ispiay Home? Yeg No <br /> n yes,a specJa!avenf permit is requir,�d with Police bepaRment and Ciry Council approva�6o days prior to tne evenG Shuttle bus service will be <br /> ' requlred unless appllcant damonstrates sufficient on-sr7e pa�king is avalfable. Non-pelmitted e�ents will no(Ge allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: , <br /> Name: �\Zct.�pQ`�'1n �-CV1Gl.1.IrJ <br /> State License# Expiration Date� <br /> Lead Certification Number. Expirativn Date: <br /> (for work on i►omCs thaf We►'e Constructed prlor M f 978 <br /> Phone: (cell) _ _ s (office) <br /> Mailing Address: '3 'S r- City: Q�Y�o ZIP:55 <br /> Contact Person: AppliCant is: Contractor / omeowne �ci«ie a�e) <br /> Email and/or Fax: ��� 2.,-Fa 2�,�C�n � QM cu�� C0� <br /> (/� <br /> PROPERTY OWN�R INFORMATION: � <br /> Name: � `1 7.�r�-� cQ � �d 2��✓1 =— <br /> Phone(day): - zIP: � -�j�.r <br /> Address� � t �, � City: �-ryy,p <br /> �mail and/ar Fax� � " �h � , <br /> PROJECT INFORMATION: Overall ro ect descn tion:M ✓ a'� ���� <br /> Type of Project: Any earth movemerrt may aleo require <br /> ❑Door(s) �emodel ❑Fire Damage MCWD review&permlts= <br /> ❑Re-roof,d8phalt ❑Repair ❑Storm Damage Minnehahs Creek Waf,�rshed DisfiCt(MGWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> PhOne: 952�7i-0590 <br /> ❑Re-fo0f,other(speclry) Q Siding �Qther(specify) Fax: 952-471-0682 <br /> ❑Window(s) .minneh& <br /> Estimsted Construction Va1uaC�on of Prolect(excluding I�nd) � I O ` ,�,.ti�� <br /> APPLIGANTACKNOWL�dGEMENT: ' �f1c{ �' ` � � � �"�� � <br /> • Agrees to provide all information requirgd or�equested by the Building DepaRment; _ 1 `�i„� <br /> Cerkifies that the information suppli�d is true and correct to the best of his/her knowledge. The applipnt recognizes thdt�iey ar� � <br /> • solely responsible for Submilting a compiete application being aware that upon failure to do so, the staff has no alternative but to � <br /> reject it until it is complel�; I�' <br /> • Some o�dll pf the information that you �re 85ked to provide on this applicati0n i6 ClaSsifiBd by 5tate law as either privat� or � �'� <br /> confidentfal, Private data is information which generally cannat he given to the publiG but can be given to the subjeCt Of th2 data. <br /> Confident�al data is informatior�which generally C2nnot be given to either Che publiC or the subject of the data. Qur purpose and <br /> irltended use of this infnrmatib is to annually update our records and reCoMs of other governmental�genGie6 required by law. If I <br /> ou refuSe to su I th � ati�on the IiC2tion ma not be issu2d. <br /> � <br /> AppliCant's Signature: Date� `� <br /> Owner's Signature: ^ Date: �I�`�� I� <br /> Last Updated:January 2015 <br /> T00�j S2II�d �'A S'Idi� 59TTL9bZi9 X�3 IS�i'T STOZ/fiT%LO <br />