|
� =' �, . � � �`w"Y">� .*�.�. c� :'
<br /> � ��;
<br /> ' ' ���y c�f O r'O n O �
<br /> . " B�ifding Permit Appiica�io� for Maintenance / RenQvatio� �
<br /> �;�;.
<br /> ,.:z
<br /> ` (windows, doors, siding, re-roof, etc.)
<br /> M,ai(ing Address:
<br />�� �,0,�. PO Box 66 Permit number.
<br /> � �„ �
<br /> Crystal Bay, MN 55323-0066 Qate received:
<br /> I,a -�'� �, StreetAddress: Received by: �
<br /> x:
<br /> �r I��'' �: 2750 Kelle Parkwa �
<br /> � � o Y Y Pfan review fee: t;,
<br /> , r9�Esxo4`'� Orono, MN 55356 ��
<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. �`�
<br /> incompfete appfications will be returned. (Please print) �,�
<br /> " GENERAL INFORMATION: � P� / �'"
<br /> zry: Job Site Address: � `�� �= �� � ,�'� .�j� ,� �
<br />��= Will this be a Parade of Homes, Remodelers Showcase Home or other Disp{ay Home? ❑ Yes o �;
<br />�, ,' !f yes, a specra/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus servrce wil!be ;�
<br /> �:' required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. ��
<br />_�;;
<br />�''' CONTRACTOR/APP T INF RMATIOI�: � �.� �'.
<br /> �;` Name: � �j'j��-� �'-� ;
<br /> .�';
<br /> State License# Expiration Date: � �
<br /> Lead Certification Number: Expiration Date: �
<br /> ��
<br /> (for work on f�omes tha were constru fed prior ?978 �
<br /> Phone: r v� ^ (office) � � ,� (cell)
<br /> Mailing Address: S � � City: IP:
<br /> "` Contact Person: , A ficant is: on a r / Homeowner `
<br /> y[ pp (Circle One)
<br /> , �
<br /> Email and/or Fax: s�r,��� ��� h , ,,�, �' ,h�• C v �'
<br />�,: PROPERTY OWNER INFORMA (�: � �
<br /> �$ Name: 0°"%"0�,� �/�-� �
<br /> �:
<br />` Phone(day): l 'O�z '�- �S�/ / '
<br /> Address: ��� �iy�tlCl ��,�`�C�/c,� �r��-P City: �/1j .� ZIP: ,��36 � �;
<br /> Email and/or Fax /jjj�r,�S �'�
<br /> ���
<br />�=;; ;M�;
<br />�:�: PROJECT INFORMATION:
<br /> Type of Project: �� Any earth movement may require i
<br /> ❑ Door(s) � ❑ Remodel ❑ Fire Qamage MCWD review&permifs:
<br /> Minnehaha Creek V1.atershed District(MCWD)
<br /> ❑ Re-roof, asphalt �2epair ❑ Storm Qamage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 f�
<br /> Phone: °52-471-Q590 �
<br /> ❑ Re-roof, other(specify) ❑ Siding �Other: (specify rax: 952-471-0682 `'
<br /> I ❑ Window(s) www.minnehahacreek.orq y�
<br /> Overall Project Description:
<br /> Estimated Construction Vaivation of Project (exciuding land) $ /�� �-�e�
<br /> ��
<br /> � APPLICANT ACKNOWLEDGEMENT: �
<br /> i • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the information supp(ied is true and correct to the best of his/her knowledge. The applicant recognizes that they �
<br /> are solely responsible for submitting a compiete appficaiion being aware that upon failure to do so, the staff has no aliernative ��
<br /> but to reject it until it is complete; �'
<br /> `�,�_,-r.� ,
<br /> - • Some or all of th ' for 4 ion that you are asked to provide on this application is classified by State law as either priva'te or I� ��
<br />�.' confidential. Pri ate d a is information which ge�e�ally cannot be given to the pubiic but can be given to the subject of tne �;
<br /> data. Confiden ial data ' information which generalfy cannot be given to either the public or the subject of tne data. Our �
<br /> purpose and int nded use this information is ta annualfy update our records and records of other governmental agencies � �
<br /> re uired b law. ou refuse to u f the information,,the a plicafion ma not be issued. ��
<br /> ;• �.
<br /> �� � � ��
<br /> ApplicanYs Signature: �-_---- --- Date: ����� � ka�
<br /> V �5`.
<br /> �s
<br /> Last Updated: 08-09-2011 ';
<br /> ,�
<br />
|