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� <br /> ��f � , h P��s����� �� ��t� �� ����� <br /> . ��elcfing Permi� A►pplication for fUiaintenance / Replaceme�t / Rerroodel — Residential Ot�Ll� <br /> �i��. ��rp�c�����, d�����; �e�€�as ������t`� �fc. — ��� ���'9�������� ����,���€�€�j <br /> �A, Mailing Address: Permit number: � Q <br /> � !y� PO Box 66 , <br /> �� �� Crystal Bay, MN 55323-0066 Date received: <br /> 5 <br /> � � <br /> Street Address: Received by: <br /> ti�, � 2750 Kelley Parkway Plan review fee: <br /> t L Orono, MN 55356 <br /> qk�SHOg� ��' � <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 �N�,,���:.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENER�iL INFORMATION: ( ( <br /> Job Site Address: � �� �� 1•� ' l-c�Ka C �{LC,� <br /> Will this be a Parade of Homes, Remode ers Showcase Home or other Displ 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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/ PPLICAIyZ INFORMATIP t� <br /> Name: �1M� �-�C �'�;v�'� I �i�� SCV�SS�'1/ <br /> State License# (,,, �`7 Expiration Date: 04� a( '� � � <br /> Lead Certification Number: �4-}- 3�0 3 fQ � Expiration Date: Q3� � ���1 �� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �a � ��� --�� (office) ��k�"fifi� � � <br /> Mailing Address: '� ' � City: ZI : <br /> Contact Person: � ��_ ��V _��cf Applicant is: ontrac or / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATI r (_ <br /> Name: �,�1� V�� ��'l�� b �/�,� 1 �� �� y� �,"1 <br /> Phone (day): " / <br /> Address: . 4 � �� City:L-c�k� �� k,� ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Fire Damage MCWD review&permits: <br /> �� � V / ���� � ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ( 15320 Minnetonka Blvd <br /> ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> C �,! ,r/ �� w�vw.minnehahacreek.orq <br /> �l_ (/� <br /> �t(excluding land) $ 1 �c��3 <br /> � � � ����(�" " � requested b the Buildin De artment; <br /> Y 9 P <br /> and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> application being aware that upon failure to do so, the staff has no alternative but to <br /> ; asked to provide on this application is classified by State law as either private or <br /> ch generally cannot be given to the public but can be given to the subject of the data. <br /> �ally cannot be given to either the public or the subject of the data. Our purpose and <br /> ly update our records and records of other governmental agencies required by law. If <br /> o� retuse to su u� m�ur w��, � a lication ma not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />