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�.i�y u� vr u��u <br /> '� Bu`ilding' Permit Application for Maintenance / Replacement / Remodel <br /> �E..4-, h'M 9�%@,tl��.'i9�q "r.A'i.6 i,J$ W`7�F `I'y3 E 1 3�e €A+'��wS� �k S.P a "' ��R Ms' w�E 3 ���ri�'1�,,.1 1�i,.,A�3+'_'t b.... �£�����`,���'.��;�f <br /> Mailing Address: Permit number: 5 -dD <br /> ���0 PO Box 66 ) <br /> Crystal Bay,MN 55323-0066 -�' � Date received: �/'-Z /S'� <br /> �' ���,� �� . <br /> (, ,� Street Address: �''� �� Received by: <br /> � 2750 Kelle Parkwa �`��C ��� <br /> ��� : Y Y � Plan review fee: <br /> � tq ti" Orono, MN 55356 ,,��i� ��� �i(�� <br /> KEs N o� <br /> ,f�"� �-� � Total Fee: �� C� <br /> Main: 952-249-4600 Fax: 952-249-4616-' www.ci.orono.mn.us <br /> This application form must be completed in full and atl required information must be submitted. �� ��L�' <br /> Incomplete applications will be returned. (Please print) � �� <br /> GENERAL INFORMATION: �,� � � ���,-J1�� <br /> Job Site Address: �C.}�z,b � ���� ^ '� "�� <br /> Will this be a Parade of Ho delers Showcase Home or other Display Home? Yes No <br /> If yes,a specia/event perm�t is required with Police Departmenf and City Council approval 60 days prior to the 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: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes fhat were constructed prfor to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: ��j �n. �V�=- City: G��U Z�P� 535� <br /> Contact Person: ��„�� �c(�t'c�„� � Applicant is: Contractor / Homeowne - �a�c�e o�� <br /> Email and/or Fax: ���U G��q o�j� (,��fi�„-,u� , � L��� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �j�u� �' ��n n� �Ol�"I c�n � <br /> Phone(day): �/ 2..- 7 K 7- �Z6 n <br /> Address: 3�2 0 � � oLv`c� CitY: a/���'l/� ZI P: �j S 3.s,� <br /> Email and/or Fax: �-r-� v�E.q}�-'r� ��a�1 ,���,,^ <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: Any earth movemeM may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(speclty) ❑Siding ❑Other: (speafy) Phone: 952�171-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Constructlon Valuation of Project(excluding land) $ <br /> APPLlCANT ACKNOWLEDGEMENT: <br /> • Agrees to provide alt information required or requested by the Building Department; <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 inform is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the in rm tion he a lication raa not be issued. <br /> ApplicanYs Signatur : � Date: ��7—�� <br /> ,_ <br /> Owner's Signature: Date: �� ���.� <br />