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� . . <br /> ��ty o� ��on� <br /> ��ilcleng Perrt�it A►pp6ic�ti�r� for �aontenance 1 ReplaCement / Remode� — Residential ONLY <br /> ' ��.�. �er������, d�s�c�, �f�e��, ��-����9 �f�e � �� �`���C�'fJ�e�;,� �3���,E������� <br /> ��� Mailing Address: Permit number: 2(�� � ���2 <br /> � PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �"� 1' �� <br /> ,� � Street Address: Received by: SP <br /> ti�, G� 2750 Kelley Parkway Plan review fee: '— <br /> �qK�SHO��, Orono, MN 55356 <br /> Total Fee: 3 <br /> Main: 952-249-4600 Fax: 952-249-4616 wU,�v�.ci_oror�o.mn.us .3, 3 <br /> This application form must be completed in full and all required information rnust be submitted. <br /> 6ncornplete applications will be returned. (P/ease print) <br /> GEIVERAL INFORIVIATION: / <br /> Job Site Address: �C/�) �fV ��' � L� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Fiome? ❑ Yes �;IVo <br /> If yes, a special event permit is required with Police Department a,nd City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. IVon-permitted events will not be allowed. <br /> CONTRACTQR/AFPLICAI�T INFORN{i4TION: / <br /> Name: �� t�t� �b� Vw �"�.( Z��� �`^C <br /> State License# �' '2� � Expiration Date: � <br /> 3 - � / Zc`�� <br /> Leac! Certification Number: �)�..�- —.�"'<a�r,�� �7_ � Expiration Date: 9 _ � 3 ._... � �-' <br /> (for work on homes that were construcfed prior fo 1978 ��'— <br /> Phone: (cell) ��/2_ ��(p - 7(d �C.� (office) <br /> Mailing Address: " L � 4,,�. �J c � ���� � , City: : .� � ZIP: �- � <br /> Contact Person: p< <r �- � �v Applicant is: Cont�rac_ tor: / Homeowner (Circle One) <br /> Email and/or Fax: � �_ ' � �/ aL, •d <br /> PROPERTY OWNER INFORIVIATIOt�: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORNiA►TION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> �oor(s) ❑ Remodel ❑ Fire Damage �CWD review 8�permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Window(s) wvvvv.minnehahacreek orq <br /> Estimated Construction Valuation of Project (excluding land) $ P-�" <br /> APPLICANT ACKNOWLEDGEIVIENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified 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 data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to a nually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I th nfo tion,t lication ma not be issued. <br /> ApplicanYs Signature: Date: ��� � /r Z��� <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />