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JUL, 26. 2013 12: 24PM SHAW/STEWART LUMBER 6514884791 N0. 944 P, 2 <br /> � City of (�rono � <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only w'rndows, doors, siding, re-roof, etc.) <br /> �- 1�T �aIII PO Box 68. PertnR nuhlbe�: � �ZS <br /> � 0 Crystal Bay,MN 55323A06 � Date reoeived: -Z�'-� <br /> Sl�et Address: �n ' Received�y: �- <br /> �' ` 2750 Ke11ey Parkway ��//'7' � Plan reView tee; <br /> `�i,����O��G 4rono,MN 55356 � " � �� �•�� <br /> Totsl Fee: <br /> Ma�in: 952-249-4600 Pax: 952-249�4616 www.ci.orono.mn.us <br /> This appliCation form must be COmpleted in full and alt required information must be submitted. <br /> Inc�mplete applications will be retumed. (P/ease prinf� <br /> GENEFtAL lMFORMATION: /� <br /> Job S`rte Addcess: Z�I 75 lro�tl�t/lEt.,l ��I� • �%D.�o <br /> Will this be a Parade of Homes,Remodelers Showcase Home or othar Display Home? Yes No <br /> �F y�,��pa!eva»t p6rr»it i5 r6quin�p with Pplipg Depdrbn9nt and C;ly Coundl approval BO days prior to the event. Shuftle bus servioe wip de <br /> requimd un/ess appllcant demonstiates sufficient on-site parldng is available. Non�pe�mitted events wif!not be 9!lOw9G, <br /> CONTRACTOR I A P�ICANT INFORMA ION: <br /> Name; At Qu�(>N � ( <br /> State License# G � Expiration Date: �1 � �o+5 <br /> Lead Certificatian Number: „y-- � Expiration Date� �i rj - �c��S <br /> (for wvrk on homes that were consL�ucfed prior to 1878 <br /> Phone: (celn .-p�2.2. (offiCE) <br /> MailingAddress: p �►��-�'F ^ T � City: IS ZIP: / <br /> Contact Person: ,r�,,4,✓ U,��z� Applicant is: ontracter / Homeowner �c����.o�.� <br /> Emai1 and/orFa�c: c.,e2.� ,q ,�,� w�� Nc. N�T� <br /> PROPERTY OWNER INFQRMATI�Nt / <br /> Name: �Q�-1_v <br /> Phone(day): �y- �� ��q � � <br /> Address: �.3�� ��.����/ (ir/?. City:_C �n./l.? Z1P: <br /> Email and/or Fax: <br /> PROJEC7INFORMATION: Overall ro"ect descri tion�`-'�l"�+�su � �r✓r ac�S /�t/ ,�XiS��- ����• <br /> sype of Project My eartt�movement may also require <br /> ❑Door(s) [�Remodel ❑Fire Damage MCWD nview�permiis: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Pamage Minnehaha Creek Watershed District{MCWD) <br /> 182p2 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55381 <br /> ❑Re-roof,other(spacify) �Siding ❑Other.(spea�y) Phone: 952�71-0590 <br /> Fax: 952-471-0682 <br /> Window(s) www.minne.h h creek. <br /> Estimated Construct[on Yaluation of Project(excluding l�nd) $ <br /> pPPL1CANT ACK[�OWLEDGEM�ENT: <br /> . Agre�s to provide all infortnation requirec�or requested by the Buildfng Department; <br /> . CerUfies that the infortna6on supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solefy responsible for submitting a complete application being aware that upon failure to do so,fhe staff hgs no altemative but to <br /> reject it untit it is aomplete; <br /> • Some or all of the information that you are asked Co provide on this application is dassified by State law as either private o� <br /> cflnfidential. Private data is information ich generally cannot be given to the public but can be given to the subject of the data. <br /> Confidenbal data is infarmation which g erally cannot be given to eithar the public or the subject of the data. Our purpose and <br /> intended use of tnis info ' n is to a ually update our re�rds and rec.�rds of other govemmental agancic3s required by iaw. If <br /> ou cefuse to su mn ' a lication ma not be issuad. <br /> Applicant's signature: Date: ��"��° r' 3 <br /> O�me�'s Signature: Date: __ _— <br /> �asc upda�eo:o�osno�a <br />