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� C ity of O ro n o ����c;r���y���.� ,�<�_�'
<br /> Building Permit Application for Maintenance / Replacement / Remodel — Resi tial ONLY
<br /> (i.e. windows, doors, siding, re-roof, etc. - NO STRUCTURAL EXPANSI N)
<br /> �O�O Mailing Address: _ ,,�,
<br /> PO Box 66 Permit number. �;�t, / ;% � �-';` - �,
<br /> Crystal Bay, MN 55323-0066 Date received: �'-i`F!%�;'
<br /> � a
<br /> Street Address: Received by: './,�
<br /> ti�, G� 2750 Kelley Parkway Plan review fee: /Vc�� /�/�.� � -�
<br /> �qkESHO�@, Orono, MN 55356 /"_
<br /> Total Fee: � �1 �L� ��--
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us i
<br /> This application form must be completed in full and all required information must be submitted. �J��� �_���7
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> JobSiteAddress: 333.3 S�o�<<��e. J,�r:�c N���crc , r� N
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: AIIvc�.-M�c-r (�oo�
<br /> State License# �(�3S Expiration Date: 3�3 1 - 1 '7
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) L! S5 - 9�/ (office) G/� -�a 1 �as�/�'
<br /> Mailing Address: P` w,�,,,,{.�, /�,,� N. City: G..•( �,� V�� � ZIP: S s"ya 7
<br /> Contact Person: $c�{�- Sfcryk,�,� Applicant is: ontract Homeowner (CircleOne)
<br /> Email and/or Fax: Sco.f-4.Lo 4,1 I aea�'�cr rod • ca•�►1
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �,c,,•�,R Foo� F�vl���.gs rnc.
<br /> Phone(day): y s, _5 /s--_r.��pS
<br /> Address: y�pv v�s� ,$"D SF City: � ,-�,� ZIP: ,$"s`�d 5�
<br /> Email and/or Fax: U c,t 1.�, �;�,l�,,,,��,h � ���.j I- , �,,,�
<br /> PROJECT INFORMATION: Overall project description:
<br /> Type of Project: Any earth movement may also require
<br /> MCWD review& ermits:
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage p
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd
<br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345
<br /> [� Re-roof,other(specify) ❑ Siding ❑ Other:(specify) Phone: 952-471-0590
<br /> �jnMMG<G;q Fax: 952-471-0682
<br /> � ❑Window(s) www.minnehahacreek.ora
<br /> Estimated Construction Valuation of Project(excluding land) $ �3,3S7•
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to
<br /> reject it until it is complete;
<br /> • Some or all of the information 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 data.
<br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the information,the a lication ma not be issued.
<br /> ApplicanYs Signature: / Date: 3I�N I � `�
<br /> Owner's Signature: Date:
<br /> Last Updated:January 2016
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