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<br />�`� • Building Permit Appiication for Mainter�ance I Renc�vation � ���"{�� ��'
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<br /> (windows, doors, siding, re-roof, etc.)
<br /> ` Mailing Address: Permitnnumber. `
<br /> ' /O�v O,�O PO Box 66 �
<br /> ' Crystal Bay, MN 55323-0066 'Date received:
<br />�: �
<br />` �� � �, I Street Address: Received by: '
<br /> ` �� ��.�
<br /> j;u \L �',����„ �� 2750 Kelley Parkway j Plan review tee: a�
<br /> '�gESKo�`'� Orono, MN 55356 j '
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<br /> Total Fee: ��"
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ,
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<br /> � This appfication form must be completed in full and all required information must be submitted. ��
<br /> Incompfete appfications will be returned. (Please print) �
<br /> GENERAL INFORMATION: Llh� �F
<br /> Job Site Address: �; ; � � _ i_- %� �/.� ,�_
<br /> Will this be a Parade of Homes, Remodefers Showcas Home or other Display Home? ❑ Yes ''
<br /> �'No ;,.
<br /> !f yes, a speciaf event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service wil!be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted evenfs wil/not be allowed.
<br />� �� CONTRACTOR I APPUCANT INFORMATIOI�: ;�;
<br />; Name: �// ��`��� L e��,fi���<=-�i��� 4�
<br /> State License # �f, � � �� � �h, Expiration Date: 3 j 3/%ry ..�
<br /> Lead Certification Number:/��f G lz�CQ y._j Expiration Qate: 7�,Gj�s- _
<br /> (for work on f�omes fhat were constructed prior to 1978 ''
<br /> Phone: i� :�� —��'J' '- �''�`�, (office) ��,.-„� (cell}
<br /> Maiiing Address: .rj j ys'�y�vs ��,;�/ l - City: ,�}���j?G�,�ZIP: �� _,,� ,::_; j
<br /> Contact Person: /�f'f: ��� �y��,�, App(icant is: ContraEtor / Homeowner (Circle One) �
<br /> Email and/or Fax: � ��
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<br />: �
<br /> f°=���� PROPERTY OWNER INPORMATION: �
<br /> Name: �-- � �� ��:
<br /> ,�D . i�l �v ./,' �
<br />;:: Phone(day): ��1.� •_ �y�; .-5�"� � � :
<br /> �
<br /> Address: �5 /� ��=� l���i= 1. ��i� City:,l��.�i�/,�`'/�,.rZIP�� > � S�
<br /> Email and/or Fax `T—'—
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require �
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits: ..�
<br /> ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) k�
<br /> �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd *�
<br />� ❑ Re-roof, cedar ❑ Restoration Deephaven, MN 55391 ��
<br />� - ❑Water Damage .��
<br /> ❑ Re-roof, other s eci Phone: 952-471-0590 ;
<br /> ( p fy) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 �,:
<br /> ❑Window(s) www.minnehahacreek.orq M�
<br /> >,�
<br />" Overall Project Description: �;
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<br /> Esfimated Construction Vafuation of Project (exciuding fand) � /(� DOD , c�O
<br /> ':�;
<br /> APPLICANT ACKNOWLEDGEMENT: �� '��"�e � �
<br /> ;�Y
<br /> • Agrees to provide all information required or requested by the Building Department; �
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<br /> .
<br /> Certifies that the information suppfied is true and correct to the besf of his/her knowledge. The applicant recognizes that they �
<br /> are solely responsible for submitting a complete app(ication being aware that upon failure to do so, the staff has no alternative ���
<br />� but to reject it until it is complete; �
<br /> �;�,
<br /> • Some or all of the information that you are asked to provide on this application is ciassified by Stafe !aw as either private or I ;;
<br /> confideniial. Private data is information which generally cannot be given to the public but can be given to the subject of the I �
<br /> data. Confidential data is information which generalfy cannot be given to either the public or the subject of tne data. Our � „�
<br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies ;,,
<br /> re uired b law. If ou refuse to su I the information,the ao iication ma not be issued. ��
<br /> I �--� d � __ �
<br />� ����� A IicanYs Si nature: iJ � ,d
<br /> PP 9 �-��—`�—�`l'l .T,�,�� Date: �_�/ Z._
<br /> Last Updated: 08-09-2011 / �
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