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05/07/2015 TxU 1a: 20 Fax 555 5555 Equua Computer Syetem� f�001/003 <br /> , City of arano <br /> � Building Permit Application f�r Malntenance / Replacement I Remodel <br /> (i.e. windows, doors, siding� re-roof, etc. — NO STRU�TURAL EXPANSIQN) <br /> Mefl/ngAddress: Permlt number: �Z � �S�—G'G J� �-� <br /> Pa Box fi6 <br /> �Q Crystel Bey, MN 55323-OOBB Dete recelved: 'r'..� —' � "'�S <br /> StreetAddress: Recelved by: L._� <br /> �F L�' 2750 Kelley Parkway Plan revlew fee; � �O�� <br /> �, Orono, MN 55356 <br /> ��f�HO� Total Fee: 5Q � < < b <br /> Maln; 952-249-4600 Fax: 952-249-4�16 ,y�w,cl,orano.mn,ufi <br /> This appllcatlon form must be completed in full and all requlred lnformakion must be submltted. <br /> Incomplete appllcativng wlll be raturned. (Please print) <br /> GENERAL iNFORMATION• <br /> JobSlteAddress: ��� L_i"��lf ��'L.�ndv���Q �+ <br /> WIII thla be a Parade of Hom�s, Remodelers Showcase Home or other Dlsplay m�? Yea o <br /> n yaa,a speclel event parmlf Is rroqufrod wlth Po!!ee DepaMment end City Counep approva/60 days prbr to the event. Shuftle bus servlce wlll be <br /> required unless applJoant damonatrates suAYclent an-slte parklna!a avallable. Non-permitted eventa wll!nat be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name� �;1 f� CiV-�l�S O "�— <br /> State Llcense# Expiratlon Date: <br /> Lead Certification Number: Expiration Date: <br /> (�or work orr homss that were constructed pr/or to 1878 <br /> Phone: (cell) � d . (office) <br /> Malling Address: � � , City: ZIP: <br /> Contact Person: Applicant is: Contracto / omeowne �c�rca on•� <br /> Emall and/or Fax� c�. ' � C'Ca� <br /> PROP�l�TY OWNER INFORMATION: <br /> Name: � vl '��,�Jt?�n.��1n <br /> Phone (day): � SZ��d-p '� Q�'3 c� <br /> Address: ���'j L���f�{ (�jv'�(•�P�� (i(�CC ti Clty: w(j Vj 2 ZIP: ,�'��f' <br /> Emall andlor Fax� � ,� . � ��.h �o��•��� l�C� <br /> PROJECT INFORMATION: Overall ro ect descrl tlon: v <br /> Type aF ProjeCt: Any ea�Ch movement may also req r� <br /> ❑Door(s) �Remodel ❑Flra Demage MCWD revlew�permlts: <br /> ❑Re-rqof,e9phalt [J RePafr ❑Starm Demege Mlnnehaha Creek Wetershed Dlelrfct{MCWD) <br /> 18202 Mlnnefonka�Ivd <br /> ❑Re-roof,Cedar ❑Restoratlon ❑Water Damage � Deephaven,MN 55361 <br /> ❑Re-roof,other(apeclfy) ❑9iding ❑Other:(specify) Phone: 852-471-0590 <br /> �ax� 652-471-0882 <br /> , ❑Window(s) www.minnehahecreek.ora <br /> Estlmated Cvnatruction Valuatlon vf ProJect(excluding land) � r�c�� U �1'� __ <br /> i APPLICANT ACKNOWLEDC3�MENT: <br /> . Agrees ta pravide all inform9tlon requlred or requested by the Building Depertment; <br /> • Certlfles that the Inform8tlorl sUpplied Is true and correct to the 49si of his/her knowledge. The appllCant recognlzes that they are <br /> solely responslble for submltting a completA appllCation being aware lhat upon failut0 io do so,ihe staff has no altemative bUt l0 <br /> reJect it until it is com�lete; <br /> . 5ome or a!I of the informatlon that you are asked io provide On thls appllcatfon Is classified by Stete law es �Ither prlvete or <br /> � ConfidenHel. Prlvete data Is Information which generelly cennol be glven to the publlc but can be glven to the suhject of tha data. <br /> Confldentl�l det& IS Irlformatlan whlch generally cannot be given to either the publlc or the subJeCt ai the data. Our purpoae and <br /> � Intended use of thls Informatlon Ig to annually updete our records and records oP other governmental ag8nCl98 requlred by lew. If <br /> � ou refuse to au Informetlan the Ilcatlon ma not ba Issued. <br /> � Applicant's Signat�ire: Date: J� � �2�l <br /> Qwner's Signature: Rate: �" / r ��� <br /> L�sl Updaled:January 2015 <br /> � <br />