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<br /> �, Buiiding Permit Appiica�ion for Mair��er�ar�ce / RenQvatio�
<br /> .• (windows, doors, siding, re-roof, etc.)
<br /> M,ailing Address: Permit number. Z v�Z -
<br /> ��v 0� PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: '
<br /> �� �. � :
<br /> , � � Received b
<br /> �a �:,: �, Street Address: ' Y�
<br /> .., � ,� E��
<br /> ��'� -'� � 2750 Kelle Parkwa
<br /> o Y Y Plan review fee:
<br /> �`�.gESKo�"� Orono, MN 55356
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> — �
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incompfete appfications will be returned. (Please print)
<br /> GENERAL INFORMATION: -, , �
<br /> Job Site Address: �.�L : �' '� ! � ; �, ,i f'� <-� , � r l<- �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dispfay Home? ❑ Yes No
<br /> !f yes, a special evenf permit is required with Polrce Department and City Council approval 60 days prior to the event. Shuttle bus service wi/!be
<br /> required unless applicant demonsfrates suffrcient on-site parking is availab/e. Non-permitted events will not be al/owed.
<br /> CONTRACTOR/APPLICANT INFORMATIO� ,
<br /> Name: l,lJ.��L�tr-� �u.,�;..r� 1•��,
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on fromes that were constructed prior to 1978
<br /> Phone: �Z- g C�7 -��� (office) (cell)
<br /> Maifing Address: �o?� — �y�S f l�,.�, � i1/, 1,�,�._ Cit : ZIP: �5�� �
<br /> Contact Person: �,�Lc-,v ,S�� � Appiicant is: Contractor / Homeowner (Circle One)
<br /> Email andlor Fax: u,,,�;'� c: � : e,�s C� �j +
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: i~j?-u� �- Su� �r �scs�v
<br /> Phone(day): Cl�'Z - �7S- ��la .
<br /> Address: gt� u,�,� �',��,� �� City: �,,t.��.t;� ZIP:
<br /> Email and/or Fax
<br /> PROJcCT INFORMATION:
<br /> Type of Project: �I � Any earth movement may require
<br /> ❑ Door(s) I ❑ Remodel ❑ Fire Damage MCWD review&permits:
<br /> ❑ Re-roof, asphalt ❑ Re air ( Minnehaha Creek Watershed District(MCWD}
<br /> p ❑ Sform Damage 18202 Minnetonka Bfvd
<br /> ❑ Re-roof, cedar �Wat� g I Deephaven, MN 55391
<br /> ❑ Restoration Ar Dama e Phone: 952-471-0590
<br /> ❑ Re-roof, other(specify) [�Sitling ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Pro�ect Description:
<br /> Estimated Construction Vafuation of Project (excfuding fand) $ �� �r-c�� --
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all inforrnation required or requested by the Building Department;
<br /> • Certifies that the informafion supp(ied is true and correct to the best of his/her knowledge. The appficant recognizes that they
<br /> are sofefy responsible for submitting a compiete appfication being aware that upon failure to do so, the staff has no alternafive
<br /> but to reject it until it is compiete;
<br /> • Some or all of the information that you are asked to provide on this application is cfassified by State law as either private or
<br /> confideniial. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the
<br /> data. Confidential data is information which generally cannot be given to either the public or the subject of tne data. Our
<br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies
<br /> re uired b law. If ou refuse to su fv tne ' " e a lication ma not be issued.
<br /> ApplicanYs Signature: /' � Date: � — �.�� j �
<br /> �ast Updated: 08-09-2011
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