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<br />�; ' B�ilc�ing Permit Appiication for IVlainter�ance / Renovation �� � � ���
<br />�� ' (windows, cioors, siding, re-roof, etc.) ��
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<br /> M,ailing Address: I O � �
<br /> /O�v 0,� PO Box 66 Permit number. —
<br /> � 0 Crystal Bay, MN 55323-0066 Date received: —/
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<br /> �a l ���`;� s� � Streef Address: Received by:
<br />' � � t ;" ti/ 2750 Kelle Parkwa
<br /> � o y Y Pfanrreviewfee:
<br /> L9'kESH04� Orono, MN 55356 �,,
<br /> ',' Total Fee: �"
<br />��; Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us p�� �
<br /> This application form must be completed in full and all required information must be submitted. ��
<br /> ��
<br /> r incompfete appfications will be returned. (Please print) ��
<br /> GENERAL INFORMATION. � , %
<br />�' Job Site Address: ��7'^ i- f"` ';i _`Y-� lt .,' ��.,� _ �,.,'�, �`�;I�� j f' �"L,�.� �
<br /> �� < < � ��=� { � � - � �
<br />�� ' Will this be a Parade of Nomes, Remodelers Showcase Home or other Disp{ay FFdme? ❑ Yes �No �
<br /> If yes, a specraf event permit is required with PoGce Departmenf and City Counci/approva/60 days prior to the event. Shuttle bus servic`�will be �
<br /> required unless applicant demonstrates suffcrent on-site parking is available. Non-permrtted events wil/not be allowed. `
<br />;,,r' CONTRACTOR/APPLICANT INFORMATIOf�: �
<br />�' Name: �_ "�- ;�; ' _ ,� :�
<br /> _ x�.,.,,: Gy.,, ;��
<br />' State License# L�:�,�-�,�7��� Expiration Date: •� ��/`-� �
<br /> ��
<br />�:' Lead Certificafion Number: Expiration Qate: �;
<br /> � (for work on ho es that were constructed prior to 1978 �
<br /> Phone: -,-�` ;� � �. ��: . �;,� (office) �'�f,,;-, _�, ,. _ ..�,� �._,-� ,_��- (cell)
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<br /> ,3; Maifing Address: ` _; c i:- ,�.-":. �� \ City:�%,�r `.vU ,� `,.. %/,,�ZIP. c:`�.� -� --
<br />� Contact Person: ,�' _ ,� �, �r��t{,J Applicant is: Contractor� / Hom OWf10( (Circle One)
<br />����� Email and/or Fax: ��v+� �7�q/��(%✓'�"�E°�:��,�-� �'��''�;
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<br /> PROPERTY OWNER INFORMATION`,_ ��
<br />� Name: r' �--�..; ,,��� �C.0 1�����
<br /> Phone(day): /f�; .v 'f 7I —O.�'?`�' °
<br /> Address: ��j ��� ,,�'��,�./ � .�"� ;%�,i� City: � j', ZIP: .� ��'���-, �_
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<br /> Email and/or Fax �C
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<br /> � PROJECT INFORMATION: �
<br />�. Type of Project:
<br /> Any earth movement may require I �
<br />� ❑ Fire Qamage MCWD review&permits:
<br /> ❑ Door(s} ❑ Remodel f�
<br /> ` ° Minnehaha Creek Watershed District(MCWD)
<br />� ' Re-roof, asphalt �Repair .Storm Damage 18202 Minnetonka Blvo �
<br /> _ ❑ Re-roof, cedar ❑ Restoration Deephaven, MN 55391 �
<br /> ❑Water Damage
<br /> ❑ Re-roof, other s eci Phone: 952-471-0590 �
<br /> ( P fy) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 �
<br /> ❑Window(s) i www.minnehahacreek.orq ��
<br /> �
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<br /> Overall Project Description: �` , -- r ; -;�._ �=�
<br /> u �y,
<br />� ` Esfimated Construction Vafuation of Project (exciuciing fand) $ ��, �=l'�- , ��' ¢�
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<br /> �� APPLICANT ACKNOWLEDGEMENT:
<br /> ��
<br /> • Agrees to provide all information required or requested by the Building Department; �
<br /> ` • Certifies that the informafion suppfied is true and correct to the best of his/her knowledge. The app(icant recognizes that they ��
<br /> �` are solely responsible for submitting a complete app(ication being aware that upon failure to do so, the staff has no alternafive ��
<br /> but to reject it until it is complete; ,�
<br /> �
<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. Confidenfial data is information which generalfy 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 govemmental agencies ;�
<br /> re uired b law. If ou refuse to su I the informafion, the a fication ma not be issued. �_.�
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<br /> ApplicanYs Signature: �—�"`�' ' _ ' Date: l �� 1���`��� �
<br /> Last Updated: 08-Q9-2011 � �
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