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+�'�:N i ."�R, . . .. , .� . . ..,. , _. ;. . ... . , .,.. . ,.. .. . k . n,. :..�. � ,. � " �i�y� O�� ro�Q : � Buil�ing Permit �,ppiica�io� for NEainte�ance / F�enova�ion �� . � (windows, doors, siding, re-roof, efc.) Mailing Address: Permit numbec / �v 0,� PO Box 66 Crystal Bay, MN 55323-0066 Date received: �� 9 � �a �a��:� �, Street Address: Received by: �'�,L a,,;;�„a„ �ti 2750 Kelley Parkway Plan review fee: 9g f�4� Orono, MN 55356 ESHD Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us - This appfication form must be completed in full and all required information must be submitted. .x fncompiete appficafions will be returned. (Please print) GENERAL INFORMATION: _ p � Job Site Address: �j.�� /v�C1^�L �)l�t 0''� l� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No !f yes,a specral event permit is required with Pofice 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 wif/not be allowed. : .� CONTRACTOR/APPLICANT INFORMATION: � Name: R�V4�-� � i< State License# a Expiration Qate: `� ---� ` �- � �� Lead Cer�ification Number: � '� ?� �� (,�Ot- � Expiration Date: L� - Q$ - aU(� (for work on homes fhaf were consfrucfed�rior to 1978 ' Phone: � � a-�� 15�7� (office) cell � ) Maifin Address: � 9 ((S7�(C� (��L ,u City. `,fl,vt 1 � , ZIP: `-1 � Contact Person: j�� Applicant is: �c br / Homeowner (Circle One) Email and/or Fax: !v w� q� R 6 i nG o r � C�v� PROPERTY OWNER IN ORMATION: Name: ` � " a v� , Phone (day): �P� �- �7 - �7� x° Address: i-� (J�v.��( i� f � City: ��.� (�t�''� ZIP: �j'� � �� Email and/or Fax PROJECT INFORMATION: Type of Project: Any earth movement may require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: Minnehaha Creek Watershed District(MCWD) ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Bivd ❑ Re-roof, cedar ❑ Restorafion ❑Water Damage Deephaven, MN 55391 Phone: 952-471-0590 �" ❑ Re-roof, other(specify) �iding ❑ Other. (specify) Fax: 952-471-0682 '�`'' ❑Window(s) www.minnehahacreek.orq '' � Overall Project Description: ,�c.� Cj, � Q'j� � � . � r� � Estimated Construction Valuation of Froject(excluciing land) � a� dOT APPLICANT A�KNOWLEDGEMENT: • Agrees to provide all informafion required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowiedge. The appficant recognizes that they are solely responsible for submitting a complete appiication being aware that upon failure to do so, the staff has no alternafive but to reject it until it is complete; �°:? • Some or all of the information that you are asked to provide on this appfication is cfassified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the :� data. Confidential data is information which generall canno e �ven to either the pubiic or the subject of the data. Our purpose and intended use of this information is to �ually d � our records and records of other govemmental agencies �� re uired b law. If vou refuse to I the inform i the li 4ion mav not be issued. ApplicanYs Signature: � //``- Date: U`� �� - G� '- �� Last Updated: 08-09-2011 �k