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06/01/2615 15:08 5073566021 AMWW BB PAGE 62/64 <br /> � City of arona . <br /> Building Permit Application for Maintenance I Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ��r Mailing Addr�ess� Permit num6er. � 'U�o � <br /> � {1/� PO�ox B6 <br /> Crystal Bay, MN 55323�0066 Date reCeived. <br /> Red2i�ed b �� ' <br /> Streef Address, Y� <br /> ��, �� 2750 KeAey Parkway Plan review fee• ��:�6� <br /> Orono, MN 55356 . `� <br /> t�R'�S H O�� <br /> Tafal Fee• 4 �� <br /> Main: 952-249�600 Fax: 952-249-4616 www.cf.orono mn.us <br /> This app�ication fprrl'f must be completed in full and all required informa#iqn m t be su mitted ��w � _ / <br /> Incomplete applicatlons wiil be returned. (Pleese print) �� / � � <br /> GENERAL INFORMATIO � � � � �� ��� � <br /> Job SRte Address: <br /> Will th�s be a Parade of Homes,Rem 61e1"S Showcase Hom other i�play Home? ❑Yes No <br /> ff yes,a specla!event pQrmit is iequired wdh Poflce Depar�ment end City Councif approval 60 days prior tu fhe event. Shutt/e AuS 56rvice will be <br /> requirgd unless epplicant demonstl'aY�s Sufficient on-site park�ng Is avaflab/e. NwrpeRnitfed evenfs Wlq not be alfowed. <br /> CONTRACTOR/APPLECA(�T INFORMATION: t, ,� <br /> Name: � �1CC�Y� � �Y'l�J <br /> State License# Explration Date: �i <br /> Lead Certifrcation Number: � Expiration Date: ��j <br /> (fol'uvork on home.s that wele Colfstructed pripr tp ��r� <br /> Phone. (cel l) '] -- $4�,`jl.�C�. '��a�L <br /> Mailing Address: 1 I�� LY-1 G� � (,� ZIP: ���� 7 <br /> Contact Person: �,r� �f^► Applicant is: Contract / W meowner �cE�i�o�a► <br /> Email and/qr F&X: �, �Yl�-2�I `� CI�.YY�e 1'1�COl.Y"�,Y1JLA. Y1/���t' •(_�; �'7�)�J- ,��QQ�� <br /> � J <br /> PROP�RTY OWN�R INFORMATION: <br /> Name: � � � <br /> Phone(day): �c� a — �'� <br /> Address� ��a) U t^I L � v u � r CitY� � ZIP: �� <br /> Email and/or�ax: ---- � �W— <br /> PRQJECTINFORMATION: O�eralt rq�ectdescri tion: �1�15�. � �}�-�.�i('�{'(„ C,�Q(� b�tSQ,yYI 1�J'x,»S <br /> Type of ProJect: • Any earth movement may also require <br /> MCWD review 8 ermits: <br /> ❑Door(s) ❑ Remadel �Fire Damage A <br /> � R�raaf,asphalt �Repair ❑Storm Damac�e Minnehaha Creek Watersh�d District(MCWD) <br /> 18202 Minnetonka Blvd <br /> �Re-roof, cedar ❑Restoration ❑Water Damage �eephaven,MN 55391 <br /> �Ra-rooP,other(speGiy) �Siding ❑OYher_(specify) Phone: 952�71-0590 <br /> Fax: g52-471-fl882 <br /> �W[ndow(s} www.minnehahacreek.orq <br /> Estimated Cpr�struc#ion Valuation of ProJeCt(�xcluding land) $ '�� a� <br /> APPLICANT ACKNQWLEDGEMENT: <br /> w • Agrees to provide all inform8tion required or requested by the Buiiding�epartment; <br /> . Ce�tifias ihat the informatian supplied is#cue and correct to the best of hislher knowledge. The applicant recognizes that they are <br /> solely responsihte for submitting a oomplete application being aware thet upon failure to do so, the steff has no altemative but to <br /> reject it until it is complete; <br /> • Some ar all of the information that you are asked to provide on this application is classified by State law as either pnvate or <br /> confldential, Private data is information which generally cannot be given to the public but can be glven{o tha subject of the data. <br /> Confidential data is infprmation which generally cannot be given to either the public dr kha subject of the data. Our purpose and <br /> intsnded use of this informatfon is to a�n Ily update our records and records of other governrr�en#al agancies required by taw. If <br /> ou reivse to s infor tton licatlon ma not be issued. <br /> ApplicanYs Signature: p�{�; `! <br /> Owners Signature: Date� <br /> Last Updated:03/68/2073 <br />