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� <br /> �i��► a�€ ��a�o <br /> `r�uiiciing Permit �►ppii�a�io� for IVEainfena�ce / F�e�ova�ion <br /> (windows, doors, siding, re-roof, efc.) <br /> Maiting Address: Permit number: <br /> /'�.,D,j� PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> �O � O <br /> �'��a,,r�-.�... <br /> �a , '.',�-�' Street Address: Received by: <br /> , M�. ,:r,''-� � I <br /> \�n ",;,?„'�, G/ 2750 Kelley Parkway Plan review fee: <br /> L'�gESHo�"� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This appfication forrn must be completed in full and all required information must be submitted. <br /> incomplete appiications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: l�,� �..��� 1���1�� �t <br /> Will this be a Parade of Nomes, Remodelers Showca e Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a specia/event permit is required with Police Deparfinent and City Counci!approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is avai/ab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��,v��k `�� .� 1,�,�._��{�w� <br /> State License# '��� �� {�� Expiration Qate: (�, �S ��,� � <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes thaf were construcfed prior fo 1578 <br /> Phone: �� �- ��}� -�'S'I b (office) <br /> (cell) <br /> Mailing Address: �� I r c.< <v�o( �z City: �� ��„�� ZIP: �c,���� <br /> Contact Person: E i ` Appficant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: � <br /> Name: ��,��y L���� �. <br /> Phone (day): 1�-' � -,�\\� <br /> Address: `` V /'4' Y� ����'�l s: S S �I <br /> z�L' � � �c •;ti Cit ZIP: � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: i Any earth movement may 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 /> I ❑ Re-roof, other s eci Phone: 952-471-Q590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> .�Window(s) � www.minnehahacreek.orq <br /> Overal! Project Description: <br /> Esfirnated Construction Valuation of Project(excluciing land} � ��C�C�. �) <br /> APPLICANT ACKNOWLEDGEM�NT: <br /> • Agrees to provide all 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 app(icant recognizes that they <br /> are solely responsibie for submitfing a compfete appficafion being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this appiication is ciassified by State taw as either private or <br /> confidentiaf. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential da:a is inform�tion which generally cannot be given to either the pubiic or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> reauired b law. If vou refuse to su I the inf rmation,the a plicafion mav not be issued. <br /> � . <br /> ApplicanYs Signature: �,y'� ,-' � ���� -- Dat,.: <br /> -- o <br /> Last lipdated: OS-09-2011 <br />