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<br />�; Bu6lding Permit Appiicafion for Mainter�ance / Renovation ��
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<br /> s� (windows, doors, siding, re-roof, etc.) ,y�
<br /> M,ailrng Address: I ��l�^� � �
<br /> �v 0,� PO Box 66 Permit number. :,
<br /> �,�\` � Crystal Bay, MN 55323-0066 Date received: - �--
<br /> a � '� -,-s� s, Streef Address: Received-by:
<br /> �� �.$,� ��.�,_ ti
<br /> � �,ti 2750 Kelley Parkway Plan review fee:
<br />��� L`�kEsxo4`'� Orono, MN 55356
<br /> I Total Fee: ��,�� �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us '��
<br /> i $�
<br /> This appfication form must be completed in full and all required information must be submitted. ��
<br /> Incompfete applications will be returned. (P/ease print) ��
<br /> �;
<br /> GENERAL INFORMATION: �
<br /> Job Site Address: �' S y� �irJ/J/c.� �j V�; �j,Qe��� � �r`
<br /> �
<br /> Will this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑ Yes ,� No �
<br /> If yes, a specia/event permif is required wifh Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be �;
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. ,.�
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<br /> CONTRACTOR/APPLICANT INFORMATIOI�: ��
<br /> Name: J ,pI�wI�S I��Vi1J 13�'Dr��— IWnF� dr �(���"21;� ,;�
<br /> State License # Expiration Date: ��
<br /> Lead Certificafion Number: Expiration Qate: "ry�
<br /> (for work on f�omes that were constructed priar to 1978
<br /> ,�
<br /> Phone: (office) j5� yS`/- 7/vj�cell) .,�
<br /> Maifing Address: � �� Corr�,���r"� ),��1- City: /1�C��nc� � g s 3(,t "
<br />'� Contact Person: A licant is: Contractor / Homeowner
<br /> 6' : Pp (Circte One) {;
<br />;�:. Email and/or Fax: ���
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<br /> : PROPERTY OWNER INFORMATIO • �
<br />' Name: J rq r✓�€S �A V )t7 �t'ae 11
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<br /> " Phone(day): �5� �J,S(� ^ �'/0 I ' �
<br /> '` Address: r- �� , y �Jb,,�� SS 3 b�/ �
<br /> �l013 Con�,v�e c � (j)v cit : , zIP:
<br /> �
<br />`�H Email and/or Fax �— �
<br />�" ; �
<br /> PROJECT INFORMATION: �
<br /> �;
<br /> Type of Project: Any earth movemenf may require .�
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits: �
<br /> ❑ Fire Qamage a;
<br /> �• Minnehaha Creek Watershed District(MCWD) �
<br /> �Re-roof, asphalt ❑ Repair ❑ Storm Qamage I 18202 Minnetonka Blvd "
<br />` ❑ Re-roof, cedar I Dee haven, MN 55391 �
<br /> ❑ Restoration ❑Water Damage p
<br /> ❑ Re-roof, other s eci Phone: 952-471-0590 ��
<br /> ( p iy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> OverallFrojectDescription: �►q2 DI� C�L� �S h,4fj— Sh�'✓r j�S ��� G'�� ��'W �Vr`t'�P� �Ce F�eLT ���/�S
<br /> Estimated Construction Vafuation of Project (exclucfing land) $ ��SOp,D�
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br />�' ` • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they
<br /> are solefy responsible for submitting a compfete appfication being aware that upon failure to do so, the staff has no alternafive
<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 cfassified by State law as either private or k�
<br /> confideniial. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the ;��
<br /> data. Confidential data is informafion 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 governmental agencies �
<br /> re uired b law. If ou refuse to su f the informafion,the a lication ma not be issued.
<br /> . � /� �� �
<br /> � AppficanYs Signature: ;,y��E/ 1 Date: (p �u la ��
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<br />'�+ Last Updated: 08-09-2011 �.
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