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- � .�: <br /> h <br /> �i�,/ O� V E'�i'�O r:,:: .;..� .� . <br />� , �� Buifc�ing Permit Appiica�ion for Maintenance / Renovatio� <br />�� <br />;K; � ' (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: � .e2p/a- D C�(o Z �] <br /> /,� � Permit number: <br /> PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Qate received:` 7' z -/ <br /> . O �, O ,� <br />� � 3 :� � Received b S <br />��: �a � ,� , Street Address: � Y• <br /> E;:y <br />" ��n ;"�'� �j 2750 Kelley Parkway Plan review fee: <br />,'` �9g� �'o� Orono, MN 55356 ": <br />�..:, <br /> a�' Total Fee: <br />� Main: 952-249-4600 Fax: 952-249-4616 wwv��.ci.orono.mn.us <br /> F.; <br />� This appfication form must be completed in full and all required information must be submitted. <br /> ° Incomplete appiications will be returned. (Please print) <br />''` GENERAL WFORMATION: <br />�:= Job Site A dress ,�G�C� �L; S,S�x �� <br /> '`'' Will this b a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br />�;'� /f yes, a s ec�a/event permit is required wifh Police Department and City Counci�approva!60 days prior to the event. Shutt/e bus service wi!!be <br /> required uNess appficant demonstrates sufficient on-site parking is avai/able. Non-permitted evenfs wil/not be af/owed. <br />��_ <br /> CONTRAC OR/APPLICA�IT INFORMATION: <br /> Name: ��U C'�,�� �, P- <br /> State Licen e # ������S—��� Expiration Date: j 3/ /3. <br /> � Lead Certifi afion Number: Expiration Qate: <br /> (for work n homes fhaf were consfrucfed prior fo 1978 <br />� Phone: �p/.� -�U�.- �-j�j v (office) (cell) <br />�. Maifing Add ess: �y,�yv q � �.� N fc_ City�.._ ,����_ ZIP: S�3 j `c <br /> Contact Per on: f%�� Applicant is: Contractor Homeowner (Circle One) <br />. Email and/o Fax: � t�;e�e f �y e��, c;; c• .r� �• ,,,.� <br />__: <br />��' PROPERTY OWNER INFORMATION: <br />� <br /> Name: �'(.�ar�c� '—c �' <br /> �s <br /> _ Phone(day): �,�� _ �� �� �s3 �� C� . <br /> Address: City: ZIP: <br /> Email and/or ax <br />��. <br /> PROJECT I FORMATION: <br /> Type of Proje t: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Qamage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, as halt �Repair ❑ Storm Qamage 18202 Minnetonka Blvd <br /> = ❑ Re-roof, ce ar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, oth r s eci Phone: 952-471-0590 <br />_ ,. ( p iy) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 <br /> ' ❑Window(s) www.minnehahacreek.orC <br />%`: Overall Froje I t Description: �,T.� S•�lz,�ic�� ;�� <br /> ��' G.��� � E' c � <br /> Esfimated Co sfruction Vaivation of Project (excluding kand) f �� .f��� ..:� <br /> APPLICANT CKNOWLEDGEMENT: <br />�: <br /> • Agrees o provide all information required or requested by the Buifding Department; <br /> • Certifie that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are sole y responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to re ect it until it is complete; <br /> • Some o all of the information that you are asked to provide on this application is classified by State law as either private or '' <br /> confiden ial. Private data is information which rally c not be given to the pub(ic but can be given to the subject of tne � <br /> data. C nfidenfial data is information whic enerally cay�not be given to either the public or the subject of the data. Our <br /> purpose and intended use of this informa' n is ta annu lly update our records and records of other govemmental agencies i <br /> re uired law. If ou refuse to su I ' formafion, e a fication ma not be issued. <br /> $ <br /> ApplicanYs Sign ture: Date: �/�/j� <br /> Lzst Updated: OS-0 -2D11 <br />