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.t��' . �� .` i� ��.� ���� . <br /> F ���y Of Q�O�o � <br /> � <br /> . • Buiiding Permit Appfica�io� for Maintenance / Renovatio� x <br /> (windows, doors, siding, re-ro�f, etc.} � <br /> � <br /> Maifing Address: , � _ j., � � <br /> ��0� PO Box 66 Permitnumber. �C ,� <br /> / C stal Ba MN 55323-0066 Qate received: j � <br /> , � �, � � rY Y. —� � -t' �-' �� <br /> s �` . ,r= RReceivedb � :O. <br /> �� ��f��,,� s, StreetAddress: � Y•� � <br />� ��L t�';��Gti J 2750 Kelley Parkway Plan review fee� �.� <br /> `�kEsxo�'' Orono, MN 55356 � <br /> Total Fee: ��� C�� '7� 3 <br /> Main: 952-249-4600 Fax: 952-249-4616 wwv��.ci.orono.mn.us �-'� ' � <br />� This appiication form must be completed in full and all required inrormafion must be submitted. � <br /> Incomplete appfications will be returned. (Please print) �� <br /> ,' GENERAL INFORMATION: -- - -: � <br />� y Job Site Address: �� � � � • � ;Ej � � ,� � <br />�.. � <br />� ` Will this be a Parade of Homes, Remodelers howcase Home or other Dispfay Nome? ❑ Yes ❑ No € <br /> ; If yes, a specia/evenf permit is required with Polrce artment and City Council approval 60 days prior to the event. Shuttle bus service wil!be <br /> wk,` required unless applicant demonstrates sufficienf on-site parking is available. Non-permitted even±s wil/not be allowed. � <br /> �� <br /> CONTRACTOR/APPLICANT INFORMATIpf�: <br /> � <br />� Name: � � � <br /> �� c��� x ✓�.5�.r���l u�t �.��, � <br />' State License# —�1 Expirafion Date: 3 -3 I — ��I �; <br />�;-� Lead Certification Number. � �"_/ �����i�) Expiration Qate: �] - � — �S �'. <br /> � <br /> � (far work on homes that were constructed prior to 1978 � <br />�, Phone: �j'� _ � �:� ._3��•�� (office) -7� ; - (cell} � <br /> : Maifing Address: �- - S City: ZIP: <br />�� Contact Person: A ficant is: ontracto ' / Homeowner ` <br /> � p{� (Circle One) <br />���� Email and/or Fax: � � � � <br /> � <br /> PROPERTY OWNER INFORMATION: <br /> � Name: � r <br /> x': Phone(day): -��y� �� ° <br />'� Address �� � City: {' - ZIP:�J��" <br />�_; Email and/or Fax � ;� <br />�_`' � <br /> PROJECT INFORMATION: ;� <br /> Type of Project: � �"� <br /> Any earth movement may require ;A <br /> ❑ Door(s) �emodel ❑ Fire Qamage MCWD review&permits: � <br /> ❑ Re-roof, asphalt ❑ Re air � Minnehaha Creek Watershed District(MCWD) �� <br /> p ❑ Storm Qamage 18202 Minnetonka Blvd �? <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � <br /> ❑ Re-roof, other s eci Phone: 952-471-0590 � <br /> ( p iy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) � <br /> www.minnehahacreek.orq � <br /> � Overall Froject Description: � <br /> �.. <br /> _ Estimated Construction Vaivation of Project (excfuding land) � `- ����� � <br /> '� <br /> APPLICANT ACKNOWLEDGEMENT: � <br /> • Agrees to provide all information required or requested by the Building Department; e� <br /> # <br />� ` • Certifies that the information supplied is true and correct to the best of his/her knowledge. The app(icant recognizes that they � <br /> ���< <br /> . are solely responsible for submitting a compfete application being aware that upon failure to do so, the staff has no alternative �� <br /> but to reject it unfil it is complete; `_: <br /> � <br /> • Some or all of the information that you are asked to provide on this appfication is cfassified by State law as either private or '� <br /> confideniial. Private data is information which generally cannot be given to the pubfic but can be given to the subject of the 'A�i <br /> da:a. Confidenfial data is information which generally cannot be given to either the public or the subject of tne data. Our �a <br /> purpose and intended use of this information is to annualfy update our records and records of other governmental agencies '� <br /> re uired b faw. If ou refuse to su f the informafion,the a fica"' ma not be issued. �: <br /> . ,, <br /> , _ __�� � <br /> ---- `� ` � l . � <br /> ApplicanYs Signature�." — - � - ..- Date: ��(� �jj� � <br /> � � - r.rq <br /> Last Updated: 08-09-2011 �� �� � <br /> � <br /> �� <br />