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City of Grano <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: i - C /a _v�8� <br /> d PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: <br /> I`f Street Address: Received by: <br /> \rpt' o~ 2750 Kelley Parkway Plan.review fee: <br /> t`�kEsxo4'� Orono, MN 55356 <br /> Total Fee: ��� oo <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: I S!) iV;;-i 4-b c li -tee 0,, o✓ ��A /e— l2to;✓1 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ONO <br /> 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 <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: jeo TI10"-t A I> it L� <br /> State License # g(_ e2 r),y,4 3,2c3 Expiration Date: T-3 r — -Ice­/3 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: ? NG40 (office) (cell) <br /> Mailing Address: -7 7,r, y c a + c e— City: fl��a• ZIP: {S y <br /> Contact Person: Uv, Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: J fiti,, �a 4 (61- t-y,+ ",( ; i c c <br /> PROPERTY OWNER INFORMATION: <br /> Name: I0 Z 4 <br /> Phone(day): <br /> Address �7 Nr�i t�/ City:f24� �IZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt ❑ Repair Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, others eci Phone: 952-471-0590 <br /> ( p fy) Siding ❑ Other: (specify) Far.: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.org <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information 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 annually update our records and records of other governmental agencies <br /> required by law. If you refuse to supply the informalian,the application may not be issued. <br /> Applicant's Signature: /�� Date: vl — 7 — <br /> Last Updated: 02-09-2011 <br />