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�i�y af Q�ono <br />� Buiic�ing Permit Appfica�io� for Mainter�ance / Renc�vatio� <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> �, 7,�. PO Box 66 � Permit number. <br /> �� � � Crystal Bay, MN 55323-0066 Qate received: <br /> � <br /> '1 Y � �;: � Streef Address: Received by: <br /> �� '� Gti 2750 Kelley Parkway Plan review fee: - <br /> \r9kEsxo4`� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 ww+n�.ci.orono.mn.us <br /> This appfication form must be completed in full and all required information must be submitted. <br /> fncompfete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br />�: Job Site Address: ���;�� �`j,�Y�� �������.� �v" <br /> Wil! this be a Parade of Homes, Remode�ers Showcase Home or other Display Home? ❑ Yes {�"Ao <br /> lf yes, a special event permit is required with Police Departmenf and City Council approval 60 days prior to the event. Shutt/e bus service wilf be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wil/not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATIOI�: <br /> Name: _���E' � � 'U�CSU�;�'lit G, <br /> State License# � P� c�(�j ' Expiration Date: ��,�`3 <br /> Lead Certification Number. Expiration Qate: <br /> (for work on homes that w re constructed prior fo 1978 <br /> Phone: �( �.- -- � � y-� (office) <br /> (cell) <br /> Maifing Address: �>� , •'r (�� City:`��� �j � ZIP: ��, <br /> Contact Person: n<<���� Appficant is: Contra�or / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNE INFORMA�ION: <br /> Name: � � <br /> Phone(day): — ' � -- • <br /> Address: � 1/ CitY: ' ('��Z ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATIOI�: <br /> Type of Project: I Any earth movement may require <br /> MCWD review& ermits: <br /> ❑ Door(s) ❑ Remodel ❑ Fire Qamage P <br /> Re-roof, as halt � Minnehaha Creek Watershed District(MCWD) <br /> �,, p ❑ Repair ❑ Storm Damage I 18202 Minnetonka Bfvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other s eci Phone: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) Far.: 952-471-0682 <br />� ❑ Window(s) www.minnehahacreek.orQ <br /> Overall Project Description: <br /> Esfimated Construction Vafuation of Project (excluding fand) $ �,��J <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 solely responsible for submitting a compiete application being aware that upon failure to do so, the staff has �o alternafive <br /> but to reject it until it is complete; <br /> I <br /> • Some or all of the informafion that you are asked to provide on this application is classified by State law as either private or � <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annualfy update our records and records of other governmental agencies � <br /> re uired b iaw. If ou refuse to su f the informafion,the a lication mav not be issued. <br /> a <br /> AppficanYs Signature: , � Date: �������� <br /> % / <br /> Last Updated: 08-09-2011 <br />