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<br /> Buifcfing Permif �ppiica�io� for IV�ainte�a�ce / Re�o�a�ion
<br />, r (window�, doors, siciing, re-�-oof, etc.)
<br /> Marling Address: � Permit number: �
<br /> ���,� PO Box 66 �
<br /> ; �Q Q Crystal Bay, MN 55323-0066 Date cecsived:
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<br /> �,� v,+� ,
<br /> �a �-� s, Street Address: Received by:
<br /> �,���> �'
<br /> ���cnt9 "Y��"�.,^�,,,��� 2750 Kelley Parkway Plan review fee:
<br /> gESKo�`' Orono, MN 55356
<br /> Total:Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �;
<br /> This appiication forrn must be completed in full and all required information must be submitted.
<br /> fncomplete appfications will be returned. (Please print) ,�
<br /> GENERAL INFORMATION: :� �,
<br /> Job Site Address: � r:
<br />,�� _�,�f� 1-�-, �� �t- ���� �� i�/ �
<br /> �
<br />� Will this be a Parade of Homes, Remodelers Showcase Home or oth Disptay Home? ❑ Yes , o
<br /> !f yes,a special event permit is requrred with Pofice Department and City Counci/approval 60 days prior to the evenf. Shuttle bus service will be
<br /> required unless applrcant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. �3
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<br /> CONTRACTOR/APPLI ANT INFORMATIOI�: �
<br /> � Name: ��,�� � ��� �
<br /> State License# Expiration Date: ,���� *�
<br /> Lead Certification Number: Expira'tion Date: ��
<br /> (for work on home haf were consfructed prior to 1978 �
<br /> Phone: �� - LfG'3 `J�,�� (office) � ' � ��f � (cell) ��
<br /> N�aifing Address: ' � ,f City: ��� - , ZIP: �-� � � �'
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<br /> Contact Person: ��„G ��_`��n�n Appi.icant is: on racto / Homeowner (Circle One)
<br /> Email and/or Fax: c� ; (p . �,�5..� � ��„-t�,ti� , �� �;
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<br /> PROPERTY OWNER INFORMATION:
<br /> �;
<br /> Name: ' i S�-t O 1/l.s �'� �
<br /> Phone (day): � �
<br /> Address: t � ��c'cc� � '"�' �3'� City:(� �/�� ZIP: �� ?�S��o �
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<br /> Email and/or Fax
<br /> PROJECT INFORMATION: �
<br /> � Type of Project: Any earth movement may require �
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits:
<br /> ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) �
<br /> Re-roof, as halt ��'
<br /> p ❑ Repair ❑ Storm Damage 18202 Minnetonka Bfvd �
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Qamage Deephaven, MN 55391 '
<br /> Phone: 952-471-Q590 �S
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: s ecif �?
<br /> ( P Y) Fax: 952-471-0682 :�
<br /> ❑Window(s) www.minnehahacreek.orq �;
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<br /> " Overal! Project Description: �
<br /> Esfirnated Construction Valuation of Project(excluding Eand) $ �
<br /> �,
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<br /> APPLICANT A�KNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department; `�
<br /> i�'s
<br /> , • Certifies that the information supp(ied is true and correct to the best of his/her knowledge. The app(icant recognizes that they
<br /> are solely resporsibie for submitting a complete app(icafion being aware that upon failure to do so, the staff has no aftemative �
<br /> but to reject it until it is complete; ;:y�
<br /> Some or all of the informafion that you are asked to provide on this appfication is cfassified by State law as either private or `^`�
<br /> • confidential. Private data is information which generally cannot 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 pubiic or the subject of the data. Our y
<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 vou refuse to su I the information,the a ficafion ma not be issued.
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<br /> AppficanYs Signature: Date: 1�- �" �/
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<br /> Last Updated: 08-09-2011
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