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' � City of �rona <br /> Building Permi# Application for Maintenance / Re�novation <br /> (windows, doors, siding, re-roo�, etc.) <br /> fvlailing Address_ Permit number: <-��l[� � l / <br /> �4,a,� PO 8ox 66 <br /> � ��ti. � <br /> Crystal �ay,MN 55323-0066 Date recePved: 5 - / b - � <br /> �r�:� <br /> a`'�`:��;�.�, �, StreeP Addr�ss: Received by: <br /> � ,rC t' <br /> �L��` '� 4� 2750 Kelfey Par#cway Plan review fa�: <br /> ,����p�- Orono,MN 553�6 <br /> Tp���88: / ` �,3 v2. <br /> Main: 952-249-46D0 Fax: 952-249-�6i6 wv�k.co.orano.mn.u5 � <br /> This applicat;on form must be completed in full and afl reqc�fred information must be subrnitted. <br /> lncotnplete applications wtll be retut`t�ed. {Please print) <br /> GENERAL 1NFORMATi�N: 1��� 1 �' <br /> Job Slte Address: � h <br /> WEl!thMs be a Parade of Homes, Rennodelers Showca or,�e ar ather Dlsplay Home? ��Yes No <br /> If yea,a spaoial event permit is requlred wlfh Police Departmenf and City Councl!appre�v�l 80 days pnor in the event. Shuttle trus servlce wl/1 bg <br /> required unless app!lcant demonatrates sutTrci�nf on�lte parklrrg!s avai�able, Nnn-permitted ev6nts wlJl not be�llowed. <br /> CONTRACTOR/AFP�ICANT INFORMATION: <br /> Name: 1� G�`t $� ���v� <br /> State License# ��„��,���� µ Expiratian Date: �f�1 � <br /> Lead Ce�ti�cation Number: (���_ �-�.�g� �� Explratlon D�te: <br /> °�I lS <br /> (f�r rvork on homas thaf were constructed prior to 7978 <br /> t�t,one: (�S 1� c'���-�C9�-�at w� (pt�ce) (cel!) <br /> M�iling Address: i�� . � °`��° U.>eS� City'�5�, : �. ._..��fP_ S�� � <br /> Contac#Person: Applicant is: n r c / �-iomeowner (Clrcle One) <br /> Email and/or�ax� � <br /> PROF'ERTY OWN�R INF MA7��N: <br /> Name: �A.t�t I'�.:r <br /> Pt�one (day): .�5� .`-1�-6— �Q�1.5' <br /> Address' ^ City� ZIP: <br /> Email and/pr Fax <br /> PRQJECT INFORMATION: <br /> 7'ype of project: My earth movement may requir� <br /> ❑Door(s) ❑Remodel ❑ Fire Darrtage MCWD review 8 psrmits: <br /> ❑ Re-roof,�$p�a�t 0 Re air Minnehaha Creek Wa#ershed Dfstrict(MCWD) <br /> p ❑Storm�amage 78202 Minnetonka Blvd <br /> �Re-ropf,cadar 0 R�storation �Watar Damage Deephavsr,, MN 55351 <br /> Phonr�: 952-�71-0590 <br /> � �]Re�roof,other(apecilly) ❑Siding Q Other. (sp�ctfy) �ax: 952-473-0682 <br /> � d Window(s) T `,�'wvr.minnei,ahacraek,or� <br /> pverall Pro�ect Descrip#ion: `�c,� � �O dO�.0 /; N ��C.i5 ' � ; <br /> Estimated CflnstruCtlot7 Vafuatiort of roJect excluding land) $ $ O,f30 <br /> APPLICANT ACKf�OV1�LEDGEMEfVT: <br /> • Agress to provide alE Infpml2iion required or requestAd by the 9uiiding DepartrTtent; <br /> • Certifes that the informat➢on supplied is true and corre�t to the bast of hlS/f'�er knoWiedge. The appElcant reCognizes that they <br /> are solely responsfb[e fqr submitting a complefe application being awar�that upon faffure to dq so, ihe staff has no afternativ� <br /> but to reJect It untf!it is compleie; <br /> • Some or sli of th� informatlon that you are asEced to provide on this applicatlon ls classifed by State law 2s either private or <br /> cAnfidential. Private data ie informatian which generaiiy cannot be given to the pubfic but can be g�ven to#hE subject of the <br /> data. Cpnfldential data is in#orrnation whieh generalEy cannot be given to eifh�r the public or the subject of the data. Our <br /> purpose and intencfed use of this infiormation is to annually update our recprds and records of other govemmental agencies <br /> re uired b 1aw. {f ou r se to su I the iniormation the a lication ma not be issued. <br /> Aoolicant's Slanature: G'�'7 9/y1G�l(,p <br /> Date: (, <br />