|
12/29/2015 09:31 FAX C�002/002
<br /> � .
<br /> Ci#y of arono
<br /> Building Permit A�pplicatlon for Maintenance / Replacement / Remadel
<br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSlON)
<br /> �Q A', MalRng Address: Pemiit number. eZ1�l 5 — D/,S 7
<br /> <VO PQ BOx 68
<br /> Crystal BBy,MN 55a23-OOQB Dste received: � �•' 2� ' I 5
<br /> �, Street Address: Received by:
<br /> s-�, �' 27'54 Kelby ParkwaY Pl�r�r�view fee_
<br /> � Orono, MN 55356
<br /> t1k�sH��� 7otalFee: ���• ��
<br /> Maln: 952-249-4BOp Fax: 952-249-0816 www.ci.orono.mn.us
<br /> ..._,_..------.,._.._.,r......�.�.�.r....�„�_._.-•.,-•,..,..,.._:_,�__,...._,...._�.,__,......._�.,._,._..,......_................_..,...._...� _..,..,,......_._..�....,_..:,........,.._.....�..�...._.._...�.�._
<br /> This application fdrm muSt be completed in fuil and all required informafion must be Submitted.
<br /> Incomplete appllcatfons wlll be retumed. (Please print)
<br /> GEN�RAI. INFQRMATIOt�: ! / $ � �
<br /> Job Site Addrsss; i 1l t Q � �/ '�/'�
<br /> Will this be a Parade vf Homes,Remodelers Showaas Hame or other Oisplay Hcme? Yes No
<br /> K ye�,a apeoJal everx permM Is required wrth Pafke Departmenl and Ciry Councll appraval BO days prlor to the event. ShutNe bus sen�ce wiJl be
<br /> requlred unless appllcant demonstrates su►Ilclant on-slte parkl�is avafleble. Non•permltfed evenfs wNl not be allowed.
<br /> CONYRACTOR/AP,PLICANT lNFORMATIONr . .
<br /> Name: Pella N�rtliland
<br /> - --- -- --- ---
<br /> State�icense# � 15300 25th Ave N. Ste 100 Expiration Date:
<br /> Lead Certification Numbe Plymouth, MN 5544'7 Expiration Date:
<br /> (for work on homes tha� Lic�BC64S�9U Ph, 763/745-1400 J s�c/� �j S�l 3�f� . G V �/7'
<br /> Phone: (cell) (office)
<br /> MailEng Address: Cit : �IP:
<br /> Confact I�erson: Applicant is� Cantracto 1 Homeowner cci.�+.o�.�
<br /> �mail and/pr Fax:
<br /> PROP�RTY OWN�R INFORMATI4N:
<br /> Name: L Li ll C �. W ! Q (��(n
<br /> Phone(daY): (, 4 y • 4
<br /> Address: !1 �+ p h i r D S 4J/��. Y'G Clty: �a �Q L 4 �'d ZIP: �' $ '� S t►
<br /> �mail and/or Fax:
<br /> PROJECT INFdR�AAATION: Overall ro'ect description:
<br /> Typa of Pr�act: Any earth movement may also require
<br /> �Door(s) ❑Remodel ❑Fire Damaga MCWD ravfew&permits:
<br /> ❑Re-roof,asphalt �Repair ❑3torm Damage Minnehaha Creeic Watershed DfsVict(MCWD)
<br /> 18202 Mfnnetonka Blvd
<br /> ❑ R�roof,cedar ❑Restoretion ❑Water Damage C7eephaven,MN 55391 ,
<br /> ❑ R�roof,other(sp�cHy} [�Siding ! � ❑Other:(specify) Phpne: 952-471-0590
<br /> Fax: 952-471-08$2
<br /> �Wlndow(s) !NY�;m�"''-�.,..�,.._.__�.,,�9
<br /> Eatimated Gonatructivn Valuetion of�ro)ect(excluding land) �
<br /> API�LIGAN7 ACKNQWLEpGEMENT:
<br /> . Agrees to provide all Infortnation raquired or requested by the Building Dep2rtment;
<br /> • Certifles that the information supplied is true a�correct to the best qF hislher knowledge. The appl(cent recognizes thet they are
<br /> solely resportsible for submitting a complete application being aware that upon failure to do so, the staff hss no aitemalive but to
<br /> reJect it undl It ie complele;
<br /> . Some or ali of the infortna0on that you are asked to prvvide on this applicadon Is dassffi�ed by State law as either privete or
<br /> Confldentfal. Prlvate data is irdormation which generaNy cannot be given to the public but can be given ta the subjact of the data.
<br /> ConfldentEal d�ta is Informetion whlch generally cennat be given to either the pubiic or the subJeCt ot the data. Our purppse and
<br /> Int6nded uSe of this Infipm�atlon Is to annualy upd te our records and records of other govemmenkal agenCi88 requirgd by law. If
<br /> ou refuae to su the infqrm�tion the a Ics n ma not be issued.
<br /> ApplicanYs Signature: ��' Date: � � � � �
<br /> Owner's Slgnature: Date:
<br /> ,__.,._.��_.. ,_�.._....,,,,�
<br />
|