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�.i�y u� vr u� �u <br /> � Bui!ding Permit Application for Maintenance/Replacement/ Remodel — Residential ONLY <br /> � (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSION) <br /> O Mailing Address: Permit number: ���—�V� <br /> � �O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: —� � <br /> Street Address: Received by: <br /> y G� 2750 Kelley Parkway Plan review fee: <br /> `� Orono, MN 55356 <br /> t�'�f 5 H 0�� <br /> Total Fee: ��� ��� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: _._, <br /> Job Site Address: --� � .� ���I`����� ����- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ' No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to fhe event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ���� 1 c.,,��i <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: 3�j ,(Ic�,,1�,� i� .� City: c%��. ?� � : .5�3`�� <br /> Contact Person: �1,�,� �„�� Applicant is: Contractor / HomeowneJ (Circle One) <br /> Email and/or Fax: -{-y,�,�- .�,,�35 �; ��,,<<,�.��..� (�/2 7�(? �d�Y <br /> PROPERTY OWNER INFORMATION: <br /> Name: ,�1�..,�. ��ti,nn z_� <br /> Phone(day): (�� 'Z "] � 0�Jy <br /> Address: `��3 3 0���v.c �c�c City: �L�<,�-2�.�<.. ZIP: !�' S�� `� � <br /> Email and/or Fax: t�.•-»�' t,,,�•�,'y -333 €�; ��mc..l- c���h <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(speciry) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> �Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ ,��u <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; __. - <br /> ----'-�- <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the info ation,the a lication ma not be issued. <br /> ApplicanYs Signature: � ���—�— Date: �I� II6 <br /> Owner's Signature: �--- �–�'��— / (� <br /> � Date: 6 6 6 <br /> �� <br /> , �l�o�l� <br />