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City of Ur�no _ .. Buildi�g Permit Application for Maintenance ! Replacerrtent/ Remodel—�2�sii�erl�i�N {�NL'Y _...�,�_�.,..,�,,M..,,�. , ,. „ , .., . .. ... (i.e. windows, doprs, siding, re-roof, etc.— NO STRUCTURAL �XPANSION) �a�r Mailing Address: Permit number: �.�� ' % _ - �c� �{y� P�Box 66 Grystal Bay,MN 55323-0088 Date received: d j St�est Addrsss: Received by. � �.� G,�.' 2750 Kelley ParkwaY Plan reviewfee: " ; �i" �t.� d a_' �y��s�o��, Orono,MN 55356 �� Tota!Fee: ,� � ' , ,1 Main: 952-249-4600 Fax: 952-249-4616 www,ci,ot�ono,m�� / , ` This applic8tion form must be completed in fu{I and all required information must be submitted. Incomplete applications will be returned. (Please print) % . - GENERAL INFORMATION: I '��' �� ` ` � Job Site Address: � �Q �obt p f pf r S"� Will this be a Parade of Homes, Remodelers Showcase Home ar other Display Horr�e? Yes No �f yes,a special evant permit ie r�guired with Polrce Pepartment and City Counci!apprvval 80 days prior to the event, 5huttle bus servrce will be required unless applicant demonstrates sufi`rcient on-site parking is available. Non-permitted evenfs wi/f nat be ellawed. CONTRACTOR!APPLICANT INFORMATION: PVame: ' W i o ��c State License# (3 C ��'�$�' Expiration Date: �7 Lead Certification Number: N�-'r��3�2 f��, Expiration Date: � {for work on hQmes thaf were constructed prior to ?978 Phone� (ceu)C763) 4-c�$-933�l-- {ot�ce) C763� .S-� -�7�� Mailing Address: �) � City: �) zIP: �S' Contact Person: A� u Applicant is: Contracto / Homeowner �ci�ia o�a� Email andlor Fax: [� K yr ;� �w t� ,Cb y� S ��.�� 1 PRQPERTY OWNER INFORMATIQN: . Name: �a�i ' ��y� �acv�.S�� Phone(day)' �� — P.sf�►.f; Address� (gpp �p� o ' Glty: Q k W ,�� IP: .5,�,3q Email andlor Fax: K F�+�tsev�!� /�(G 5'�. Cp� _ / PROJ�GT INFORMATION: Overdll projeCt desoription: S►tt, G�S[-N�.�e 1'f' �++dC R�wtH�� +'X�w�l�. 7ype of Project: Any earth movement may also requira �Door(s) ❑Remodel ❑Fire Damage MCWD review 8�permits: ❑ Re-roof,asphalt ❑f2epair ❑Storm bamage Minnehaha Creek Wstershed District(MCWD) 15320 Minnetonka Blvd ❑Re-roof,cedar ❑Rest,oration ❑WaGer Damage Minnetonka,MN 55345 �Re-roof,other(spaciiy� �Siding �Qthsr.(specify) Phone: 952�71-0590 Fax: 952-479-0682 ❑Wlndow(s) �RV)'SS www.minnehahacreek.org Estimated Construction Valuation of Project(excluding fand) $ APPLICANT ACKNOWLEDGEMENT: • Agrees to pravfde all Infarrnatlon requlred or requested by the euilding Department; • Cerfifies that the informatlon supplled Is true and oorrect m the best of hls/her knowledge_ The applicant recognizes that they are solely responsible far submitting a complete application being aware that upon fallure to do so,the staff has no alternatl�e but Fo rejecC It unt11 It Is complete; • Some or 811 of the irlform&tion that you are asked to provide on this application is classified by Stata law as 9fther private pr canfidentiai. Private data is information which g�:ner�lty cannot be given to the public but can be given to the subfeCt of the data. Confidential data is information which generally cannot be glven to elther the publlc or the subject of the data. Our purpose and inFended use of thls fnformatfon Is ta annually update our recorrls gnd recnrcis of other governmental agencies required by Iaw, {f ou�efUse to su I the information,the a ion ma not be Issued. Applicant's Signature� Date: � � � Owner's Signature: Date: Last Updated:January 2�16