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i:i;i �, � - '• �E�}/ Q� O�'OiIO B�ilding Permi� Appfica�ion for Maintenance / Renovation (windows, cioors, siding, re-roof, etc.) Mailing Address: Permitnumber. f� �4?v 0,� PO Box 66 ` /� � Crystal Bay, MN 55323-0066 Date received: � z�'-� �<�, , �� � ��;� s, Street Address: Received by: �''".� �';� Gti 2750 Kelley Parkway Plan revi e: �9�Esxo4`� Orono, MN 55356 Total Fee: �� v(� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incompfete appfications will be returned. (Please print) GENERAL INFORMATION: $"�' Job Site Address: rjQ r�� C l �t�� �;` Will this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑ Yes ❑ No � : If yes, a special event permif is required with Polrce Department and City Council approva/60 days prior to the event. Shuttle bus service will be ` required unless applicant demonstrates sufficrent on-site parking is available. Non-permitted events wif/not be al/owed. �..; '` CONTRACTOR/APPLIC NT INFORMATIOI�: ��. Name: hr� Sc��s �,6� C� nst State License # C 2 3� 63�3 Expiration Qate: v'3 (�3 � -��3 Lead Certification Number: QQ��,�� Expiration Date: �'"' (for work on homes fhat were constr cted prior fo 1978 ¢�3' Phone: �6'�- 23"Z- Z3i.6 (office) �63� Z3� "Z'3�6 (cell) ;�`. Maifing Address: 1523 �1��; ��(. y: ��'E`1(a Z�p: S53 t Cit VF; Contact Person: M�� (L Applicant is Con racto / Homeowner (Circle One) ' - Ernail and/or Fax: �� k� ` " PROPERTY OWNER INFORMATION: L Name: S'�,�,m� Q�:��r� ;., Phone(daY): q S�- �t�3� 'Z`lB$ �, �: Address: (��, i P�r �� h ,: <<�e - City: Lo�a j�1r.c ZIP: s �.� �,w;° Email and/or Fax �a,; PROJcCT INFORMATION: ��' T e of Pro'ect: YP J Any earth movement may require � ❑ Door(s) ❑ Remodel MCWD review&permits: ❑ Fire Qamage ,� �Re-roof, as halt � Minnehaha Creek Watershed District(MCWD) p ❑ Repair ❑ Storm Damage ; 18202 Minnetonka Bivd �:- ��` ❑ Re-roof, cedar Deephaven, MN 55391 , ❑ Restoration ❑Water Damage ❑ Re-roof, other s eci Phone: 952-471-0590 ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 ❑Window(s) i www.minnehahacreek.orq Overall Project Description: �'�"�� ,�-t-f � �,., �-}�,,,; • ,� G�,:�{ t r ,,. �P Esfimated Construction Vaivation of Project ( xciuding land) $ �� Sc�c d �'";' ;�" APPLICANT ACKNOW�EDGEMENT: �; • Agrees to provide all information required or requested by the Building Department; � • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The appiicant recognizes that they � ' are solely responsible for submitting a compfete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; ;v • Some or all of the information that you are asked to provide on this application is classified by State law as either private or +,` confideniial. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the data. Confidenfial data is information which generaliy cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies re uired b law. If ou refuse to su f the inrormafion,the a� iication ma not be issued. ApplicanYs Signature: m� S�� Date: 6 �2�5"� J Z �ast Updated: 08-Q9-2011