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<br /> . . . ���y Of C��O��
<br /> � Buiiding Permit Appiication for Maintenanc� / Renovatio� �
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<br /> + (windows, cfoors, siding, re-roof, etc.) �
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<br /> Mailing Address: ��Permit number. C�(� _ �.;
<br /> /�v 0,� PO Box 66 �
<br /> �`- � � Crystal Bay, MN 55323-0066 Date received: ��� � Z
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<br /> �a �� a, Street A ress: Received by:
<br /> �\t r ,���,ti 2 a0 Kelley Parkway Plan review f
<br /> 9.rr�SHog Orono, MN 55356 � �
<br /> ��'C� 7�� ��
<br />� , Total Fee: �
<br /> q s Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ,,
<br />'�'� This applicafion form must be completed in full and all required information must be submitted. �
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<br />� `- fncomplete applications will be returned. (Please print) �
<br />°�` GENCRAL WFORMATION: ,// ��
<br /> > Job Site Address: /l�� � (I CCS'/i�,c1 /�Q
<br />'�:. Wil! this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> !f yes, a specral event permif rs required wi�h Po(ice Departmenf and City Counci/approval 60 days prior to the evenf. Shuttle bus service wil!be �'
<br /> required unless applicant demorstrates sufficient on-site parking is available. Non-permitted events wi!!not be allowed. S�
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<br />"' �Q.N_TRA��/APPLICANT INFORM�101�: . ��
<br /> Name: �-LCSi/}� «>NS'f`(I.s�/c'�z�-, ,,
<br /> :: State License # � �� - �
<br />, �� �v(v 3 /J 7 S! Expiration Date: 3�
<br />� LL Lead Certificafion Number. Expiration Date:
<br /> �
<br /> (for work on homes that were constructed prior to 1978 �
<br />� Phone: 7��j— L�7�-�'_ �7� (ofFice) cell `
<br /> Maifing Address: �'i c%� 1,�,�.�j S7�2< <a c.. S-� City: , („��ra ZIP: �'` � ) �
<br /> Contact Person: �
<br /> � C_-�(Le� Applicant is: ontrac o / Homeowner (Circfe One) �
<br /> '' Email and/or Fax:
<br /> �
<br /> PROPERTY OWNER IN RMATIO1�:
<br /> :�
<br /> Name: /,�jv,�zw� GI
<br /> Phone(day): .
<br /> Address: /'16� �CC$�3� 2n City: ��� o ZIP:
<br /> Email and/or Fax
<br /> PROJcCT INFORMATION:
<br /> Type of Project: Any earth movement may require �
<br /> MCWD review&permits: �'�
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD} �
<br /> �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ��:
<br />� ''� ❑ Restoration Deephaven, MN 55391 �
<br /> ❑ Re-roof, cedar ❑Water Damage j ;�
<br /> Phone: 952-471-0590
<br /> 3 ' ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �
<br /> tt ❑Window(s) www.minnehahacreek.orq I
<br /> E..: �
<br />�: Overall Project Description: ��' (��
<br />�.: Esfimated Construction Vafuation of Project (excluding fand) $ /�:���,'` �,;
<br /> ��:: APPLICANT ACKNOWLEDGEMENT: � �'
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<br /> • Agrees to provide all information required or requested by the Building Department;
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<br /> Certifies that the informafion supp(ied is true and correct to the best of his/her knowledge. The applicant recognizes that they
<br />�.'� are soiely responsible for submitting a complete application being aware that upon failure to do so, tne staff has no alternative
<br /> but to reject it until it is complete; �
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<br /> r,� Some or all of the i�formation that you are asked to provide on this application is cfassified by State law 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 r
<br />�� data. Confidential data is information which generally 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 govemmental agencies
<br />� f reQuired b iaw. If ou refuse t i tne information,the a fication ma not be issued.
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<br />�. ; Applicant's Signature: i` � Date: � � ��� �
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<br /> Last Updated: 08-09-2011 '�
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