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Gity of arono <br /> Building Permit Appli�ation for Maintenance / Repla�ement ! Remodel - ���it���i���il Df��iY <br /> �, ,, .,.�,,,,�.,4�.�U�,� <br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUGTURA�. EXPAN310N) <br /> Mailing Addr�sss: � <br /> ���� Pem,it number. Z C� - ' (� <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0�fi6 Date recelved� - / - <br /> � <br /> Streat Address.. Rece9ved by: . <br /> � �� 2750 Kelley Psrkway Plan revlew fee: « <br /> �l G Orono, MN 55358 <br /> q'�.SHO�� <br /> TaCa(Fee: G�`� C�� <br /> Maln� 952-249-4600 Fax= 952-249-461fi www.ci.orona.mn.us <br /> This application form must pe completed In full and all required infqrmation must be submitted. <br /> Incomplete�pplications will be returned. lease prinfJ. " <br /> GEN�RAL INFORMATIOPI: ` �f.�Z%t���c� L3C�.' - . <br /> Ja6 Site Address: ZOZ�I' .$�Ywoaol �o� <br /> WIII thls be� P�rade of Homes, I�emodelers Showcase Home or other bispldy Home? Yes No <br /> If yes,a spacla!event perrnit fs requirsd wdh Polrce Departm�nt and C12y Councf!appmval 6P days prior tn the event. Shuttle bus servlce wll!6e <br /> requi�d unless applicant derrlonstratgs sufi5cient on-srte parking is availabla. Non-parmftted�vents will nof be aUoived. <br /> CONTRACTOR/APPLICANT �NFQRMATIaN: <br /> Name: y� ��w � <br /> State License# �C�(,S",��tr Expiration Date: �( j <br /> Lead Certification Number� ��r ��� ��'- � Expiration D�te: �.�J� <br /> ���-/�� <br /> (for►w�ork on homes that�v�ere constructed pr/or to 1978 <br /> Phone: (cefl) (7L3� y„sg -c�'3��.. (aifice) (7(,�) ,�y�-277,5 <br /> Mailing qddress: �,�; yvte.�' L /�/ City: � �� zIP: �5-�- <br /> Contact Person: �y� (ZK���r Applicant is� ontractar / Homeowner �c�«�e one> <br /> Email and/pr Fax: <br /> PROpERTY pWNER INFQRMATION: <br /> IVame: �tl✓� 9 �P i C 1r <br /> Phone (day}: �6�2} S��},-a�� <br /> Address: ,Z02,�}- S�nd�./womc� �c� �` City. prsw, ��„ty�} ZIP: ���� <br /> Email and/or Fax: S k� . A. K�� �a y�;j .Gp� <br /> . <br /> PROJECT INFORMATIQN: Overafl praJecf descri tion: ; le C�fe►a�,tf�e r�SS ; �V. � e ►�u���, �S�SnI� �w� <br /> Type of Project: Any edl'th movement may also require <br /> ❑Door(s) [1 Rem�de! ❑ FirB Damags MCWD revlew 8�permits: <br /> ❑ Re-roof, ss halt p � 9 Minnehaha Creek Watershed District(MCWD} <br /> p ❑ Re air Storm bama e <br /> 15320 Minnetonka Blvd <br /> �] Re-roaf, cedar ❑ Restoration ❑Water pamage Minnetonka,MN 55345 <br /> Re-roof,other 6 �Cj Phone: 952-471-0590 <br /> ❑ { p fy) 0 Siding ❑�#her: (specify) Fax: 952-471-0682 <br /> �W indow(s) �nrrvw.minnehahacreek.ors� <br /> Estimated Construction Valuation of ProJect(excluding land) $ 1 ,��0 <br /> APPL�CANT AGKNOWLEDGEMENT: <br /> � Agrees to provlde all(nfarmation requi�sd or requested by the 6uilding Department; <br /> • Certifies that the information suppl{ed Es true and correck bo the best of his/her knowledge. The applicant recognizes fhat they are <br /> solely responsible for submitting a complate applica#ion being aware that upon fallure to do so, the stafF has no alternatfve but to <br /> reject it un61 it is complete; <br /> • Some or all of the information that you are,asked to provide ❑n this application is classified by State law as either private or <br /> confidential. Privake data is informafion which generally ca�nnot be given to tha public but can be glven to the subject of the data. <br /> Cvnfidential data is information which generaEly cannat be given to eith�r the public or the subject of the dafa_ Our purpose and <br /> intended use of this information is to annually update nur records and records �f other governmental agencies required by law_ If <br /> au r�fuse to su I the inform tion the ation ma nvt be issued. <br /> Applicant's Signature: D�te: ��3�I� ,,,, <br /> Owner's Signature: Date: <br /> Last Updafed:January 2016 ���� � ��,/ ��l' <br /> ��r% t t-'� � ( <br />