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� � <br /> Ci�y of �rono <br /> Building Permrt Application �or Maintenance / Renovation ' <br /> (windows, doors, siding, r�-roof, etc.) <br /> P✓Jailing Address: <br /> ��.cL�0 �� PO Box 66 Permit number Q� ��j— C�C� �p <br /> (/Qy �O\ Crystal Bay,MN 55323-0066 Date received: "Z —� <br /> T; <br /> ,� U�'�„�z �, �,� StreetAddress: Receivedby: <br /> 1��` <br /> �'�,c, ��1����,���,.. ti�' 2750 Kelley Parkway Plan review fee: <br /> ��s��'��Y��^4�G Orono,MN 55356 <br /> k�s�o �a`��l <br /> J Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 ww�u.ci.orono_mn.us <br /> This applicafion form must be compleked in fuil and all required information must be submitted. <br /> IncornpEete applications will be returned. {Please print) <br /> GEt�ERAL INFORMATION: / / /n ,,, <br /> Job Site Address: c�,�Jr L�/1Gt�dI"� Nc�v <br /> Wifl this be a Parade of Homes, Remodelers Showcase Home or other Dispfay Home? ❑ Yes No <br /> If yes,a specia!event permrt is requrred with Police Department and Cify Counci!approva!6D days prior fo fhe evenf. Shuftle bus service will be <br /> required unless applicanf demonstrafes sufficient on-site parking is avaifable. Non-permrtted events wi!!noY be allowed. <br /> CONTRACTOR I APPLICANT INFORMATlO ' / <br /> Name: ' /�e�o�C� � 1"P1"/D/�5 <br /> State License# �eDOag�� Expiration Date: � � l <br /> Lead Certification Number. n/��� �p � . ,� Expiration Date: �����d0 <br /> (for work on homes that were consfructed prior fo 1978 <br /> Phane: , � �,-r'�� (office) (cell) <br /> Mailing Address: � Ciky: �'s p ZIP: <br /> Contact Persan: Applicant is: 4ntrac or Homeowner (Circle One) <br /> Email and/or Fax: � <br /> PROPERTY OWNER WF RMATI <br /> Name. �j^� �S <br /> Phone(day): �� _�j8 , <br /> Address: �?` �I2�I�1L/�� �L�-- C��� (/�D�d Z1P: 5,5,35� <br /> Email and/or Fax <br /> PRf3JECT iNFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑Remodel ❑Fire Damage MCW�review 8 permits: <br /> Ntinnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑Repair ❑5torm Damage 98202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,othef{specify) ,�Siding ❑Other:(specify) Fax: 952-471-0682 <br /> ❑Window(s) www-minnehahacreek.orq <br /> Overall Project Description: - P / l 2/��5/` � <br /> Estimated Canstruction Valuation of Project(exctuding land} $ ,' ��_G <br /> APPLICANT ACKNOWLEDGEMENT: <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 applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is complets; <br /> • Some or a[I 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 cannof be given to the public 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 the 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 au refuse to sup ly the infor ation,the ap licatian ma not be issued. <br /> Applicant's Signature: Date: -� �� �� <br /> Last Updated: 08-09-2011 <br /> �`��� <br />