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C�t� of �ron� Building Perrn6t App�ic�to�n for tVflaintenance / Repiacernent / Rer�odel — Residential ONLY . ��.�e �e��s ��.f�, ��'E€��, ��a��s �f�. � �� E��,E� �3��°�E��j � �o�o Mailing Address: Permit number. L C�� n � %� PO Box 66 Crystal Bay, MN 55323-0066 � Date received: 2- _ - j � � Street Address: (� �� �� Received by: �''',�-i- ; _/,C ti G� 2750 Kelley Parkway �/ ' � � Plan review fee: ' lqkFSH04�, Orono, MN 55356 � Total Fee: 93,�9 Main: 952-249-4600 Fax: 952-249-4616 �:��;,,.ci orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: �� ;' c� (j ��'"1�c��.�f �� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Flome? ❑Yes ❑ No 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 repuired unless applicant demonstrates sufficient on-site parking is available. Non-permitfed events will not be allowed. CONTRACTOR/APPLICANT IIVFO ATION: Name: �, - ,,. � �.� ��s _ - ��,� _ State License# / Expiration Date: '� _. /' � Lead Certification Number: c � � �j�� Expiration Date: �- ,S� ��p�?/ (for work on homes that were consfructed rior to 1978 Phone: (cell) �� - � �.z7�j (office) �_.._...._- Mailing Address: j �Kc �� "�, � �> City: �/,�;(,�� ZIP: ��`� Contact Person: G«^,-,..5 Applicant is: Co` ntracto / Homeowner (CircleOne) Email and/or Fax: �� ' � n � I- , ` �.� '� - �- ' , �d PROPERTY OWNER I�ORMATIO� � Name: /� !' _ �y'f' ^5�� r7� , �� Phone (day): Address: Z��v' L��S'r{�� ., ��,�/ City: ��,�� ZIP: Email and/or Fax: /�i'l �/2J � r PROJECT INFORIVIATION: Overall project description: � �f / , Type of Project: Any arth movement may also require ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 15320 Minnetonka Blvd ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka, MN 55345 ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590 Fax: 952-471-0682 ❑Window(s) w�nnnr.minnehahacreek.orq Estimated Construction Valuation of Project(excluding land) $ z �' D APPLICAfVT i4CKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally 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 required by law. If ou refuse to su I th�.i ormation�the a lication ma not be issued. � �� '.r � � G�l ApplicanYs Signat�(re �-- �'°� � Date: `7 C(� ' �� Owner's Signature: Date: Last Updated:January 2016