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FEB/10/2017/FRI 10: 17 AM Elder Jones Building FAX No, 952 854 4909 P. 002/002 City of aror�o B�i�Eding Permit Application for Maintenance/ Replacement/ Remodel — Residential 4NLY � (i.e.windows, doors, siding, re-roof, etc,--NQ STRUCTURAL �XPANSIpN) Mailrng Address: �, ,� �__, r ��Q PQ eox 66 Permlt number: n� , - Crystal Bay,MN 55323-0066 Date recelved; ?. � i- .� SPrest Address� Received by: f+ � � 2750 Kelley Parkway � � Plan revleW fee: - - ��KFSHo�'� Orano,MN 5535fi ' � �Total Fee: ��'� � �%t.'� �. ��C� Main: 952-249-4600 Fax: 952-249-4616 ydww.ci.oronomn.us This application form must be completed in full and all requfred information must be submitted. Incamplete appiications witl be returned. (P/ease prinf) GENERA�fNFORMATION: Job Sfte Address: ��2. s[, �d {�,�'� � Will this be a Parada of Homes,Remodelers Showcaae Home or other Display H�me? Yes No If yes,a speclal event permif is repuired wifh PoJice DeparYment and Gity Council approval 60 days prlor ro the�vent. ShuttJe bus service wi11 be requlred unlF-----'=---'��-^--+•��^��l�i��+��_�r�,�„e,a.;,,,,:��yailable. Non-permlrred ev�nts will not be allowed. CON7RACTOR!qPPI x��'`��-�o�x�e Servxce, Ii�c, Name: 2G90 Cu�llbexland Pkwy, Ste 300 State License# � �t�azzta, GA 30339�3913 Expiration Date: �r��I'� Lead Certlfication Num �,ic#C�Z268257 Pl�,. 7G3/542-$826 �{27(��xpiration Date: �� (�.-�p (forwork on hom�e..j------ ------------• . (office)q5Z�3`f.S GO,S7�-..11,�,c•�•� � Phone: cell Mailing Address: City: ZIP; ^� Contact Per$on: Applicant i _ Contractor / Homeowner �cireiav�a� Email and/or Fax�f+ W��oS •��r}r� PROP�RTY OWNER 1N�012MATfON�: p Name: �-�(1lC�lAF_1 DG�,,rlr�� Phone(day): `�� t f 7�.�',�"� Address: City: ZIP: �mail and/or Fax: PROJECT INFORMATION: Overall ro�ect description: Type of ProJect: y earth movement may also require ❑Door(s) ❑Remodel ❑Fire Damage MCWD review&permlts� ❑Re-roof,asphalt �Repalr ❑Storm Damage Mlnnehaha Creek Watershed Distrlct(MCWD) ❑Re-roof,cedar 15320 Mlnnetonka Bivd ❑Re5toration �Water pamage Minnetonka,MN 55345 ❑Fte-roof,other(specify) ❑Siding �Othel';(speClfy) Phone: 952-471-0590 Fax: 952-479-0682 �Window(s) www. hacreek.or �stimated Construction Valuatlon of Praject(excluding land) $ r APPLIGANT ACKNOWLEDGEMENT: • Agrees ta provide all Informatfon required or requested by the Sufld€ng Department; • •Certifies that the informativn supplied is true and carrect to the best of his/her knowledge. The applicant recognizes that they are sofely re&ponslble for submitting a complete application being awate that upon failure to do so, the staff has no a�ternative but to reJect it until it is complete; � Some or all of the information that you are asked to provide on this application is class)fled by 5tate law as either prlvate or confidentlal. Private data is information which generally cannat be glven to the public but can be given to the subject of the data, Confidential data is information which generally c�nnot be given to either the public or the sub}ect of the data. Our purpose and intended use of thls Infor atlon is to annually update our reCords and recofds of other governmental agencies required by law. If ou refuse to su I t information,the Ilcatlon ma not be issued. Applicant's Signature; Data: Owner's Signature: , Date: Last Updated:January 2018