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- �c�� of �ron� ��@c�in� �er°rnit Applec�te�� $��° fV��ir�tenance / Repiacement / I�ernocle@ — Resodential OIVL� (�� r��, do��°�, ��c�€��, �y�m¢��, �tc. — !��- ��;,f� ��E�ffv!� lvlailing Address: �� i� �o�Q PO Box 66 Permit number: _ Crystal Bay, MN 55323-0066 Date received: � ��(q "`(� � � Street Address: Received by: �' - ti�, �� 2750 Kelley Parkway Plan review fee: � Orono, MN 55356 � � �kESHOR� To�F e�� . Main: 952-249-4600 Fax: 952-249-4616 �v��,�,�.ci.urunomn.u� This application form must be completed in full and all required information must be submitted. /�,,N Incoeripiete applications will be returned. (P/ease print) µ�' GEI�ERAL INFORMATtON: �f/' Job Site Address: � ,� �4f� /��/L� �J✓� �✓�l�e Will this be a Parade of Horr�es, Rerroodelers Sho�nrcase Home or other Display Home. ❑Yes f�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 wiil not be allowed. GOI�TRACTOR/APPLlCANT IIVFORflAATION: �� Name: /��7fs� �� jG/i��j ��- � State License# ��5/�,2p Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were construcfed prior to 1978 Phone: (cell) (office) Mailing Address: �/� C� o �/,j� �� Cit ZIP: �,��' Y� Contact Person: _`�'�l�� ,�,,y.,._ ,-. Applicant is: Contractor / Homeowner (CircleOne) Email andJor Fax: PROPERTY OWNER INFORM�4TIOOV: Name: ��`,0 Phone (day): Address: City: ZIP: Email and/or Fax: PROJECT iNFQFtMATiO�: Overall project description: Type of Project: Any earth movement may also reguire ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) ❑ Re-roof,cedar 15320 Minnetonka Blvd ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specify) [�,Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) www.minne�i.:l,��,�.�eek.oiU Estimated Construction Valuation of Project (excle�ding lane�) $ � e' APPLICANT i4CKNOWLEDGEME�1`. • 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 generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If ou refuse to su I the information,the a lication ma not be issued. Applicant's Signature: �!%��'` � Date: � /��/ � - �� , � Owner's Signature: Date: Last Updated:January 2016