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Ju�,, ?5. 2016 2; 15PM No, 2722 P, 3 <br /> City of Oror�o <br /> Su�ldin Permit A plicat�on for Maintenance I Replacement 1 Remodel Reslden��' <br /> - g p tia101�,�.� <br /> • • ION) <br /> (�.e,w�ndows, doors, sedin re-roofi, �tc.^NO STRUCTiJP�AI, EXP�NS � <br /> Malling Address: Perrj{��t��umber � ' <br /> �L�� PO 9ox 66 ' � 7 D <br /> � C slal Ba , MN 55323-0066 Date d � � <br /> _ rY Y . -. . ,, <br /> recelVe <br /> St/eet Add�ess: �eceived by <br /> y �C' 2750 Kelley Parkway �lan f£v�e�++!fee A <br /> � G` Orono,MN 55356 <br /> � �sH��`�� Tofal�e� �� ,�� <br /> Main: 952-245-46Q0 Fax; 952•248-4616 ci.or .mn.us : <br /> 7his applicatian form must be completed in full and all required Intormativn must be submitted., <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL IN�ORMA710 :� • V <br /> Job Site Address: <br /> Will thls be a Parade of Ho►nes, Rernodelers Showcase Ho or other bisplay Home? Yes No <br /> !/yes, a spec�a!euent pemdt!s required with Pol�ce Deparfinent and GPy Council apprnva!60 ciays prlor to fhe event. Shuftle bus s , ilf he <br /> Iequlred unJess applicanf demonstrates sufBcient on-site parking is availabla. Non permllted events w!!1 not be alloweci. <br /> CONTRAC70R/A�LI ANT INFORMA710N: � <br /> Name� r <br /> State License# Z Expiration Date: �2a <br /> Leatl Certification Number: Q • Expiration Date; S ~�j <br /> (for work on homes that were consirucied prlor to 1978 <br /> phone: (cell} � � (Q � (offfce) <br /> Mailing Address: � City; � ZIP� � <br /> Contact Perspn� Applicant is: ractor• l. Nomeowner tc�r�ia o�a� <br /> Email and/or Fax: • <br /> PROPERTY OWNER 1N�OR ATIO ' <br /> Name: � �AS� <br /> Phone(day): � y ��� Z1P:�� �j� <br /> Address: ��� ��.� �it � " `� =-'L—` <br /> Email and/or Fax: , <br /> PROJECT IN�ORMATION: Overall pra ect descri tion: ( CX�� �-� �� �lS�� �h�� <br /> Type of Project: , Any eart movement may also requlre <br /> MCWD review&permlts: <br /> ❑Door(s) ❑Remodel ❑Fire bamage Minnehaha Creek Watershed Distr(ct(MGWD) <br /> 0 Re-roof,as.phalf ❑Repair ❑Storm Damage 15320 Minnetonka�Ivd <br /> ❑Re-roof, cedar ❑Restoratian [�Water Damage Minnetonka,MN 55345 <br /> ecif Phone: 952-471-0590 <br /> ❑Re-roof,other(gpe�lfy) ❑Sidinc� ❑Other�(sp Y) Fax: 952-471-0682 <br /> indow(s) .minn2hahacreek,Qrq <br /> Estimated Constructio Valuat�on of ProJect(eXcluding land) $ � � <br /> APPLICANT ACKNOWLEDG�MENT: <br /> . F�grees to provfde all information required or requestetl by the Building Department; <br /> Gerlifies tliat the fnformation supplied is true ar�d conect to the bast of his/her knowledge. The applicant recognizes that they are <br /> solely responsible For submitting a compiete application being aware that upon failure to c!o so,the staff has no altemative bui to <br /> I-eject it until it is complete; <br /> • Some or all of the information [hat you are asKed to provide on this application is Classified by State law as either private or <br /> confideniial. Privata data is inform�lioa�which generally cannot be given to the public but can be c�iven to the subject of the data. <br /> Confdentfal data is Information which generally cannot be given to either the publle or the subject of the data. �ur purpose and <br /> intended use of this information is to annually update our records and records of other c�overnmental agencies fequir�d by law. If <br /> ou reFuse lo su 1 the i f rmation,l e a lication ma not be issued. <br /> ApplicanYs Signature: h� Date: � � <br /> Owner's Signature: pate: <br /> Lasl Updatetl;Januery 2016 <br /> I <br />