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C��y of Orono O'�
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<br /> Building Permit Application for Maintenance / Replacement / Remodel
<br /> (i.e. windaws, doors, sidir�g, re-roof, etc, — NO STRUCTURAL EXPAN��QN)
<br /> Mail�n Address: y �'.�r�,; �k, pi��'� i� � � � �.�,�
<br /> ��* g a��rr�nn�mber � _ �"" �,�',.° � �
<br /> '�. 1 V PO Box fi& �"`��`d ' w� °�:.� ,�w,,,�; t ,;��
<br /> �'. Crystal Bay,MN 55323-0066 bate:recelved •- "`�{�h`�r�
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<br /> � st,�er add►�ss: A��t� „ � �,�
<br /> .� � ���d�� ������ �� r� �w
<br /> y ���'� 2750 Keltey ParkwaY ��Isn'rew�w Ee ''���' Ui,� ���, r � � �i� �=
<br /> �( ��'' �'� Of0110� MN rJ'r'J.�J6 ,h,� ��iw� i°�cr��yr.dri i ��Vt , � i �� r,� ��
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<br /> �"�YQ['��'F��E-��" M ri+B�,�� i�ls� .��ax *�,p.�.'�. n at
<br /> Mafi: 852-249-4600 Fax: 852-249-4616 no.mn.us '� ��,�,�" r'i,l�i�ti��i"iiii'w�'��r.�i ^�}��F'i;,��'
<br /> This epplication form must be completed in full and all required information must,b�s�bmi M�� �/'
<br /> Incomplete applicatlons wlll be returned. (P/e�s�pr/nt) J� � � !7
<br /> G�NERAL INFbRMATION: ��� � � � �
<br /> Job 81te Address. _.,,
<br /> Wlil thts be a Parade of Homes,Remodelers Showcase ome 4r other Dlsplay Home? ❑Yes Na
<br /> If yes,B Sp9Cla1 aveni permlt Is requlned wlth Police Departr»9nt snd C/ry Cound!approva/60 days pnor to t►te event. Shuftle bus servlce wlll be
<br /> required unless applicant demonstr6tss auA7cl�nt on�fte parking is svaila6le. Non-permlYPed events wllf not be a0owed.
<br /> CONTRACTOR I APPLICANT INFORMATION:
<br /> Name: � pp 4�
<br /> State License# '��, (�q a SS y _ ExpiraEion Date: � �r
<br /> Lead Certitication Number: �-�T--� �p ,� �� .-� Expiration bate: �'�) I� �/�p��"
<br /> (for work on homea thaf were constructad prior to 1978 �—� r
<br /> Phone: (cell) (office) ` �j - — ��
<br /> Mailing Address: ' �-� .� City: �- ZIP: j",�"b�
<br /> Contact Person: � m-r� Applicant is; Contractor / Homeowner (C�rC�t�ne)
<br /> Email andlor Fax: -}- t'"� r' "p.d� � l
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �h'c v� 1 � �.! ��.l,��v1 ����
<br /> Phone(day): �(a �. ��� (�dU'3
<br /> Address: �,�p ���„ �� �� City: (`�^(7b1 b ZIP: �S�j�Q
<br /> Email and/or Fax:
<br /> PROJECT INFORIIMA�'ION: Overall ro ect descri tion: `���`L' �' l O(� �S�w,�-�...J� _� � ( j�
<br /> Type of Project: Any earth movement mey also require
<br /> �Door(s) ❑ Remodel ❑Flre Damage
<br /> MCWD review&p�rmltS:
<br /> ❑Re-roof,asphslt ❑Repafr ❑Storm Damage ��nneh$ha Creek Wat�l�hed Dist�iCt(MCWD)
<br /> 18202 Mlnnetonka Blvd
<br /> ❑Re-roaf,cedar ❑Restoration ❑Weter Demage Deephaven,MN 55391
<br /> ❑ Re-roof,other(speclf� ❑Siding �Other:(specify) Phone: 952-471-0590
<br /> Fax: 852�71-OB82
<br /> ❑Window(s) _���___ www.minnehahacreek_orc�
<br /> Estlmated Construct[on V�luatian of Project (excluding land)W $
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building oepartment;
<br /> . Certifies that the information supplied is true and correct to the best of nis/her knowledge. The appllcant recognizes that they are
<br /> so3aly responsfble Eor submitting a complete application be[ng awdre that upon failure to do so,the staff has no alternat}ve but to
<br /> reject ft until it is complete;
<br /> • Some or all of the lnformation that you are asked to provide on this appllcation is classified by State law as either private or
<br /> confidential. Prlvate data is info�matian whlch genarally cannot be given to the public but can be given to the sub]ect of the data.
<br /> Confidantlal data is infortnatlon whlch generally cannot be given to either the publfo or the subject of the data. Our purpose and
<br /> Intended use of fhis informetlon is to annually update our recor�s and records of other govemmental agencies required by law. If
<br /> ou refuse to su I t � formation,t fication ma not be issuetl.
<br /> Applicant's Signature: p2te: I — I � ( �
<br /> Owner's Signature� Date:
<br /> Last Updated;January 2015
<br /> troo�zoo�d SSS09BLlS9(�'� ss:�� s�oz��ar�o
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