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�� o� �� ��ablcli�g Perrnit i4pplication for I�aint�n�nce / Replacement / Rernodei — Residenti�l 06�L� ` �i.�� w�€c��r�t �z��€��; �`s�i��, ��—��a��j ��e � I�� T��S�� 3��,�� �o� Mailing Address: Permit number: � � o PO Box 66 Crystal Bay, MN 55323-0066 Date received: Street Address: Received by: � � . ti�, G� 2750 Kelley Parkway Plan review fee: `� t �, Orono, MN 55356 �KES H o� .7 Total Fee: 7 U"I _ , Z Main: 952-249-4600 Fax: 952-249-4616 vv�r,��.ci.orono.mn.us L O\Q This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GEIVERAL INFORMATION: Job Site Address: '�.v (�.�►.+� �'� ('tp,� Will this be a Parade of Homes, Remoeielers Sho�rcase Home or other Display Home? Yes No If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTR�OCTOR I APPLIC�4NT INFORMATiON: Name: State License# Expiration Date: Lead Certification Number: Expiration Date: (for work on homes that were consfructed prior to 1978 Phone: (cell) (office) Mailing Address: City: ZIP: Contact Person: Applicant is: Contractor / omeowne (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: o r►�'� ��c�C�' Phone (day): y sj a ao j 7� �( Address: � � �„c� C�o C�_� ��- R C� City: (S rc.+ c. ZIP:,tj�'j 3 9j Email and/or Fax: �(orrre. . Wgcene.� Yv►e,�r�'t�..� G�o�y;'C, Cq�� Lc.r, PROJECT INFORMATION: Overall project description: Type of Project: Any earth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) f�Re-roof, cedar 15320 Minnetonka Blvd ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) w�ww.minnehahacreek•orq Estimated Construction Valuation of Project(excluding lanci) $ C300 .G p i4PPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that u are asked to provide on this application is classified by State law as either private or confidential. Private data is informa o which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information whi h enerally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is t a nually update our records and records of other governmental agencies required by law. If ou refuse to su I the information t a lication ma not be issued. Applicant's Signature� �/�� Date: p, ^ � �� 7 Owner's Signature: Q Date: �� — /�� ' (7 Last Updated:January 2016