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� .� �� ►� �Ety► a� ��n� � � ��if�iin Permit �► iica�ior� for IVE i g pp a ntenance / F�e�ova�ian (windows, cioors, sidi�g, r�-rvof, etc.) Mailing Address: Permit number: - (/6 � j�v 0,� PO Box 66 � Crystal Bay, MN 55323-0066 Date xeceived: � � I�'�'' � I,� � �c';� �,� Street Address: Received by; \ d�1> � �, � �ti 2750 Kelley Parkway Plan review fee: L'�kEsxoti`� Orono, MN 55356 Total Fee: /`�� J� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �� ,�,- (/ V� This appiication form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATIOf�: JobSiteAcidress �1 -j� J�kn�c� ��;��L;h; �'� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No If yes, a specia/event permit is required with Police Department and City Council approva(60 days prior to the event. Shuttle bus service will be required unless applicant demonstrafes sufiicienf on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR(APPLICANT INFORMATIO�l: Name: �11��_ti ��-Si 1�F=1��{/�.� State License# �;��-� c�l(��-] Expiration Date: �� ,/yl,�t� Lead Certification Number: Expiration Date: (for work on homes thaf were constructed prior to ?978 Phone: �-�.5�-(�``j�7 � ��i(i�� (office) �j'�r�_ �7/5...�7.�ej (cell) Maifing Address: -. � � � ��C�;y,�� ,' City: ZIP: ��>>� � Contact Person: ;_S��,�,u � N Applicant is: on ractor' / Homeowner �c��ie o�e� Email and/or Fax: -�-��,V� ��S .� T7 - , PROPERTY OWNER INFORMATIO�f: Name: _S i �-1��--� �'l�l� t l�i'�LC_ ��lLF� Phone (day): �IZ` -?�C�g- vz�� Address: �i'��; ;Jr�-/Yl FS�w�s� `-,D City: ��I't,'L: ZIP: ��, Email and/or Fax PROJECT INFORMATION: Type of Project: � Any earth movement may require i � � MCWD review& ermits: ❑ Door s ❑ Remodel ❑ Fire Damage P ; Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ❑Re-roof, ceclar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 ❑ Re-roof, other s eci Phone: 952-471-Q590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �Window(s) www.minnehahacreek.orq I Overal! Project Deseription: �%��y)�;��'�- t� ��:j�E l� � r�i;l��-�; �-- �i'ZE- C-�%r� ��r `�t- Esfirrated Construction Vatuation of Project(excluding land) � ,�� L��;G: APPLICANT A�KNOWLEDGEMENT: • Agrees to provide all informafion required or requested by fhe Building Department; • Certifies that the informafion supplied is true and correct to the best of his/her knowledge. The app(icant recognizes that they are solely responsible for submitting a compfete appficafion being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this appfication is classified by State law as either private or confidential. Private data is information which qenerally cannot be given to the pubfic but can be given to the subjecf of the data. Confidential data is information which generally cannot be given to either the pubfic or the subject of the data. Our purpose and intended use of this informafion is to annually update our records and records of other governmental agencies reauired b law. If vou refuse to su I the information,the ap fication mav not be issued. AppficanYs Signature: �� - % _��,/�� Qate: / , � �astUpdated: OS-Q9-2011