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May. 14. 2015 11 : 33AM Dale Gruber Constructio� No. 0395 P. 2 <br /> t�ity ot urano <br /> �uilding Permit Application for Maintenance 1 Repiacement / Remodel <br /> (i.e. windows, doars, siding, re-roof, etc. — NO STRUCYURAL EXPANSION) <br /> �0�� Ma11IngAddress: permit number: 2�� �� � <br /> PO Box 66 I' � <br /> Crysial Bay,MN 55323-00B6 Date recelved: '�^� <br /> Sfroet Address: Recefved by� <br /> ��, G�� 2750 Kelley Parkway Plan review fee: (� Qt- <br /> �,�k�sHo��, Orono.MN 55356 � <br /> Total Fee� ��� � � <br /> Main: 952-249-4800 Fax: 952-249-46'f6 www.ci.orono.m�.us <br /> This application form must be completed in full and all requlred fnformatfon must be submitted. <br /> Incomplet�appficatlons wlll ba returned. (Please print) <br /> GENERAL INFORMATION: � <br /> Job Site Address: �y� G�/� S�'��; Q�Q/t�l�! �y .�'�„$� <br /> Wllf thls be a Parade of Homes�Remvdelers Shawc'ase Home or other Dlsplay Home? ❑Yes �No <br /> I/yes,a speclal even!permlt 1s requlreal wifh Police Department and Cify Couna!apprnvaJ sp days prior Ip the event- Shuflle bus se�vlce w/A be <br /> required unless appllcanf demonslrates sull�rGent on-site padcing ls available. Non permilfed evenls will nof be a!lowed. <br /> CONTRACTOR/APPL CANT INFORMATION: <br /> IVame: � <br /> State License# � �, Expiration Date; � � �, � <br /> Lead Certification Number: � Expiration Date: .� <br /> (!or work on homes�hat woere cons ructed p or to 978 <br /> Phone: (cell) p— z (office) ,��p_-��9— �f�0 p <br /> MailingAddress: l�o �S��7j ��-�,� p�� Cify:�}-, �'�� ZIP: � 7�� <br /> Cantact Persan; � Applicant is: �/ Homeowner �c�rc�.oee� <br /> Emailand/orFax; � ��L �jy��yf��Ls � �'0vvl orr �����.�'��' 3/9�� <br /> PR�P�RTY OWNER I FORMATION: <br /> Name: .{� [ <br /> Phone(day): /� -- / <br /> Address: �� City:Q/��/p ZIP: J.�� <br /> Email and/or Fax: Cyl1� L/ C <br /> pRQJ�CT INFQRMATION; Overall ro'ect descri tion: n�� it7r" D d �/ �d�/��- <br /> Type of ProJect: Any earEh movement may also requlre <br /> �Door(s) ❑Remodel ❑�'ire bamage MCWD revlew B permlY,s; <br /> ❑Re-roof,asphalt �Repslr ❑Storm Damage Minnehaha Creek Walershed Dislrict(MCWO) <br /> 18202 Mlnnetonka Blvd <br /> ❑Re-roof,ceclar ❑Restoration ❑Water Damage Oeephaven,MN 55391 <br /> ❑Re-rooF,other(specl(y) ❑Siding ❑Olher�(speClfy) Phone� 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ara <br /> �stimated Construction Valuation af Project(excluding land) $ � <br /> APPLICANT ACKN�WL�DG�M�NT: <br /> • Agrees lo prpvide all Informatbn requ(red or requested by ihe euilding Depariment; <br /> • Cerlifies thal ihe informalion supplied is inia ahd correcl io tha besk of hislFiar knowledge. The applica�i recognizes ihal lhey are <br /> sofely responsible for submilting a complefe applicalion being aware thal upon faifure io do so, Ihe slaff has no alterrtalive bul io <br /> reJect It unt+l It Is complete; <br /> • Some or a0 of the inFormation lhat yo are asked to pravide an ihis application is classified by Slate law as eiiher private or <br /> confidenlial. Pnvate dala is Informa n hlcn general[y cannoi be gfven lo Ihe publlc bu!can be glven to(he subJect oFihe dala. <br /> Canfidential data is' maiion wh' ge erally cannof be given Io either the public or Ihe subject of the data. Our purpose and <br /> intended use oF fhi info tion is an alty updafe our records and records of olher gpvern ental agenaes required by law. If <br /> ou refuse io su I the inf a' ,1h licalion ma not be issued. <br /> Applicant's Signature: bate: � ` <br /> Owners Signature: Date: <br /> Last Updated�January 2015 <br />