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<br /> ' Building Permit Application for Maintenance / Replacement / Renovation
<br />� ` (No structural expansion. Only windows, doors, siding, re-roof, etc.)
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<br /> Mailing Address: Permit number: �� _
<br />�� ��� PO Box 66
<br /> ¢ Crystal Bay, MN 55323-0066 Date received: �/
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<br /> x `Y Street Address: Received by:
<br /> y � 2750 Kelley Parkway Plan review fee:
<br />�;.' `�t,y �,�' Orono, MN 55356
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<br /> ,', Total Fee: � �� ��
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted. i;
<br /> Incomplete applications will be returned. (Please print)
<br /> 4�� GENERAL INFORMATION:
<br /> A' Job Site Address: �t� ;6 ����� L��d�� /?�c
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No ,;
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus serv�ce will be k�
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ;:�a
<br /> �,, CONTRACTOR/APPLICANT INFORMATION: „�
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<br />��"� Name: ,Crl1 �(��r-.�l 1�c . �
<br />�: State License# � �, Expiration Date: � 1�.�.,: , � � "'_� -' �'
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<br /> Lead Certification Number: ,�__r_ ;,�k;::- �„--n � ;µ^ Expiration Date: ��
<br /> (for work on homes that were constructed prior to 1978 ��
<br /> Phone: (cell) �� i �� _ :� t --„ (office) �� ; , � :�-� _ � �' �
<br /> Mailing Address: � ��� ,�,. � Ci � � %' /'�✓ ZIP: �-C-,',� ? �
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<br /> Contact Person: '�,,� ,-,� Applicant is: Contracto / Homeowne� (�irc�e one) �
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<br />� Email and/or Fax: ��
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<br />�,: PROPERTY OWNER INFORMATION: ,�
<br /> • Name: �;'��k L� � kw�� 1 °
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<br />�Y� Phone (day): ?�j -YY 3 � 9��'Y
<br /> Address: lo3k �^;�� �.�d�. f�vz City: /���.-�( ZIP: 5 S �6�I ,�
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<br /> Email and/or Fax: �
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<br /> PROJECT INFORMATION: Overall project description: >�
<br />�:. Type of Project: Any earth movement may also require `°
<br />�''� ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: _
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> �Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ' ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
<br /> Fax: 952-471-0682 �:;:
<br /> ❑Window(s) www.minnehahacreek.orq �'`
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<br /> Estimated Construction Valuation of Project(excluding land) $ ( �, ��S ��� �
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<br /> F>�; APPUCANT ACKNOWLEDGEMENT:
<br />`'y • Agrees to provide all information required or requested by the Building Department;
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<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 comptete application being aware that upon failure to do so, the staff has no alternative but to
<br /> � reject it until it is complete;
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<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
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<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 /> k=` Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br />'�y" intended use of this information is to annually update our records and records of other governmental agencies required by law. If
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<br /> ou refuse to su I t information,the a lication ma not be issued.
<br /> ��' ApplicanYs Signature: ;� � Date: � � ��� ��
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<br /> Owner's Signature: � Date:
<br /> " Last Updated:03/06/2013
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