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• City of Qrono <br /> ' Building Permit Application for Maintenance I Renovation <br /> windows, doors, slding, re-roof, etc.) <br /> MaiJing Addreas: �::�`: ; , ° . . <br /> PO 8ox �e�it riii�; ;, ''�._���o'�::f:�l�1?��f;: <br /> '¢�.11t ss - 'r'�'�'.;;� _ ::. <br /> .; :. .. . ,:- <br /> Q 0 Crystal Bay,MN 58323-0068 t�ete_�N�il;�� '.::�' <br /> StreetAdd �39c�iSN�d, � -: ' - <br /> ross: � ':;� <br /> � 27 0 - - - <br /> 5 Kelte Parkws <br /> � Y - - <br /> y r.����'��VV��f�.{::�;���'�.: <br /> Orono,MN 55356 � - ' <br /> °,�'iD�ei,.� :;:s� ';'�`.:: :�. _ <br /> Main• 952-249-4600 Fax• 952-249-4816 www.cf.orono.mn.ua ,�'', " � ���'z',.�'��`'��'r�="' <br /> . ,,:. .. 3 <br /> This application form must be compfeted in full and all required informationtrmust be"submitted./ ' <br /> Incomplete applicetions will be returned. (P/esse pdnt) <br /> QENERAL INFORMATION: �+G , /���` S�O/L � �2 �/�wyvo <br /> Job Site Address: 7a �v r� <br /> Will this be a Parade of Homes�Remodelers Showcase Homs or other Dispiay Home� Yes No <br /> K ya,a spedel evenf penMt 1s required wNh Paflce Depe�bnsnt and City Council approve/QO days prlor lo the ever►t. Shutt/e bas servke w1!/be <br /> requlrod un�ea app/kent demonsUetee suRicJent on-a/te parMng is evsllabfe. Non�pem�d(ted everMs wl!!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: �/ , ' <br /> Name: ',✓ o ��:r! LUriST S � � �S�5,�� <br /> State Ucense# Expiratlo Date: • . <br /> Lead Certification Number: ��//��-��/ Expiration Date: /p_���� <br /> (for work on hanss that r►�ne conatrycted prlor to 1978 � <br /> Phone: -.,�, '(o s!0 (office) (cell) <br /> Mailing Address: City: ,$� Z�p; <br /> Contact Person: ,t/ � Applicent i Contr ctor / Homeowner �cir�i.o�.� <br /> Email and/or Fax: � ' � u ,r� , � <br /> PROPERTY OWNER INF RINATI <br /> Name: �s.i �� �S�-,� <br /> Phone(day): _ _ S d <br /> Address: 3SL9�/Uoit� f�'DYc� ,��t CItY' �Q ZIP• S�35 / <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> ryps ot ProJect: <br /> My aarth movement may requlre <br /> ❑Door(s) ❑Remodel ❑Fire Damage MCWD revisw d�permits: <br /> Mfnnehaha Creek Watershed Distrid(MCWD) <br /> �Re-roof,esphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-r�oo�csdar ❑Restoretlon ❑Water Damage Deephaven,MI� 55394� - . � _ _.. <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(sp�ely) ❑Siding ❑Other:(specify) Fex: 952�71-0682 <br /> ❑Wfndow(s) www.minnehahscx�eek.ora <br /> Overall Pro ect Descri tlon: ,� p � � �op� <br /> Estimated Constructlon Valuat on of Pro ect ex luding land ; p <br /> APPLICANT ACKNOWLED�iEMENT: <br /> • /lprees to provide all fnfortnaUon requlred or requested by the Building Department; <br /> • Cerdfles that the(nfortnation supplied is true and correct to the best of his/her knowledge. The applicant reoognizes that they <br /> are aolely responsible for submitting a complete applicallon being aware that upon fallure M do so,the staff has no altemative <br /> but to reJed it until ft is wmplete; <br /> � Some or a!I cf the informatlon that you are asked to provide on this applicaUon fs daasifled by 3tate law as either privata or <br /> conMieMial. Private data is informatlon which ganerally cannot be given to the public but can be given to the subject of the <br /> data. CoMidentfal data 1s infortnatlon whlch ganerally cennot be glven to aither fhe public or the subJed of tha data. Our <br /> purpose end Irnended use of this in ation is to annuelly update our records and rocords ot other governmerKel agencfes <br /> re ulred b law. H u refuse to I the Infor tlon the a Ifcetlon ma not be issued. <br /> Applicant's Signature: " Date: �/5� /2- <br /> L.est Updated: 08.p9.2p11 <br /> £00/i00f�j XV,3 £Z�ST ZTOZ/8T/90 <br />