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C��y o� ��°oa�� ��i6c96n� �err�it Application for F1�aintenance / R�piacement / f2emodel — Residential Ot�� ��.�� wir��a��, cEa��y ��:p�my c��y ��e @ �� Y��`"4��;� ��f��!�E��a , �o�o Mailing Address: Permit number: PO Box 66 Crystal Bay, MN 55323-0066 Date received: a � Street Address: Received by: tiF G� 2750 Kelley Parkway Plan review fee: �,yk�SNO��, Orono, MN 55356 Total Fee: Main: 952-249-4600 Fax: 952-249-4616 w��,�4��..ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL IIVFOITMATION: Job Site Address: 4�� GQ�/1(',�'I�j'�i� �y� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �o If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/�OPPLICANT INFORI�IATION: Name: '� <- ' P(�. �- �S State License# �" 5 Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were constructed prior to 1978 Phone: (cell) �`( (office) ` � Q�� Mailing Address: - ^,•2 �' City: � ZIP: Contact Person: , Applicant is: Contract / Homeowner (Circle One) Email and/or Fax: e_� ` PROPERTY OWNER INFORMATIO : Name: ''�'�� o��V' Phone (day): — SS Address: G' 5C` , V � �yf-- �„� City: ZIP: Email and/or Fax: '7Ca--� —�� _��`�c� PROJECT IIVFORMATIONl: Overall project description: Type of Project: Any earth movement may also require ❑ Door(s) � Remodel ❑ Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,asphalt �pair ❑ Storm Damage 15320 Minnetonka Blvd ❑ Re-roof,cedar [�'�estoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 Window(s) �vww.minnehahacreek.ora Estimated Construction Valuation of Project(excluding lanci) $ i4PPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application 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 application is classified by State law as either private or confidential. Private data is information which rally cannot be given to the public but can be given to the subject of the data. Confidential data is information which ge rally ca ot be given to either the public or the subject of the data. Our purpose and intended use of this in rmation is to annu Ily u at our records and records of other governmental agencies required by law. If ou refuse to su I t inf rmati n,the a licati a not be issued. Applicant's Signature: Date: L( ✓ 1 Q _1 � Owner's Signature: Date: Last Updated:January 2016