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.� , „(��"� '�j <br /> . �e�''�l <br /> Cit of 4rono � 1,� �5. � <br /> Y <br /> Building Pe mit Appiication for Maintenance / Reno <br /> (windows, doors, siding, re-roof, etc.� <br /> Mailing Add►ess: Pertnit number. l3�d/`� <br /> O�,�,�.0 PO Box 66 ,/- <br /> Crystal Bay, MN 55323-0066 Date received: ��1'� <br /> �, Street Address: Received by: ---�a��1�.-- <br /> �'.�,t y G�" 2750 Keliey Parkway Plan review fee: <br /> �t�.���.$ Orono,MN 55356 <br /> Total Fee: <br /> Main: 952-249-46 Fax: 952-249-4616 www.ci.qrgn�,mn.us <br /> This application f rm must be completed in full and ap required information must be submitted. � <br /> Incomplete applications wili be returnsd. (P/ease print) i <br /> GENERAL INFORMATION: <br /> Job Site Address: 2 j l <br /> Will this be a Parade of Hom s,Remodeiers Showcase Home or other Display Home? Yes No <br /> /f yes,a special event permft is req insd with Pollce Department and City Council approval 60 days prior to the event Shuttle bus service wil/be <br /> required un/ess appli nt demonstrates sutllclent on-s/te psrking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT NFORMATION: <br /> Name: � '?I4W1� GO►J $?Yt,�7GT�rJ i <br /> State License# � Q b ( Expiration Date: ?p <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were con trucfed prfor to?978 <br /> Phone: — � (office) 'Z,•'Z� -Z (celt <br /> Mailing Address: �_c,,v;)t Z,�� City: IP: <br /> Contact Person: Applicant is: racto / Homeowner �ci��o�>i <br /> Email and/or Fax: _..�- ES.�µ� tJ <br /> PROPERTY OWNER INFORM TION: <br /> Name: hy - �x�l t'' �G�7'K� la o L�t`�t <br /> Phone(day): �$ _ � _ <br /> Address: �b0� � ^ -� City:��j'. t,ot?=5 n�rt�t ZIP: <br /> Email andtor Fax GA . L <br /> PROJECT INFORMATtON: I <br /> Type of Project: Any ea�th movement may require <br /> ❑Door(s) ❑ model ❑Fire Damage MCWD review&permit�: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑ pair ❑Stonn Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑ storation ❑Water Damage �eephaven,MN 55391 <br /> Phone: 952-471-0590 , <br /> ❑Re-roof,other(speaify} ❑ ding ❑Other.(specif}r) Fax: 952-471-0682 <br /> ❑ indow(s) www.minnehahacreek.ora ' <br /> Overall Project Description: �� /p <br /> Estimated Construction Valu tion af Project(exctudi�g fand) S Z fb =- <br /> APPLICANT ACKNOWLED EMENT: <br /> • Agrees to pravide all info ation required or requested by the Building Dspartment; <br /> • Certifies that the infortnati n supplied is true and correct to the best of hisTher kr�owl�ge. The applicant recognizes that ey <br /> are solely responsible for ubmitting a complete application being aware that upon failure to do so,�e staff has no aitem 've <br /> but to reject it until it is plete; <br /> • Some or all of the inform tion that you are asked ta provide on this application is classffied by State law as elther privat or <br /> confsdential. Private data is infortna6on which generally cannot be given to the public but can be given to the subject of the <br /> data. Confldential data i informadon which generatly cannot be givsn to either the public or the subject of the data. ur <br /> purpose and intended u of this information is to annually update aur records and records of other govemmental agen es <br /> r uired b law. If u re e to I th � fo afi the a icaticm ma not be issued. <br /> Applicant's Signature: Date: �' !���3 I <br /> Last Updated: 08-09-2011 <br />