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i <br /> ! ` City of Urono <br /> Bu Iding Permit Application for Maintenance 1 Renovation <br /> (windows, doors, siding, re-roof, ete.} <br /> Mailin Address: �� _ Q� � <br /> ;�0,�.� PO Box 66 Permit number: <br /> �/ i Crystal Bay,MN 55323-0066 Date received: �� <br /> ��o ��!?� r- ' Received by: <br /> y,z,�, �, i� Street Address: <br /> �'�c, �;,�.�.���„�'�` � 2750 Kelley Parkway Plan review fee: � <br /> �-s}g"�`•�����w arono,MN 55356 <br /> �EsBo <br /> -- Total Fee: ' <br /> Mai : 952-249-4600 Fax: 952-249-4616 wvv�v_ci.orono.mn.us <br /> Thi applicafion form musk be compfeted in fulf and all required informatian must be submitted. <br /> Incomplete appl'rcations will be returned. (Please prinf) <br /> GENERAL !P[F MATION: <br /> Job Site Addre s: ��1����(� � �,,� �,�� <br /> WiEI this be a P rade Of Homes, Rernodelers Showcase Home or ather Dispfay Home? ❑Yes „�-l�Fo <br /> If yes,a special vent pqrmit rs required wifh Police Deparfinent and Cr(y Councrl approva!60 days prior to fhe event. Shutfle bus service will be <br /> requ ed un!.gs applrcanf demonstrafes suffirient on-site parkrng rs available. Non-permifted events wi!!nof be a/lowed <br /> CONTRACTOR APP�ICANT INFORMAT[ON: <br /> Name: � <br /> State License# -7 " Expiration Date: 21.�� <br /> Lead Certificatio Number. ���-���S^� Expiration Date: �-:_��p <br /> (for work on h mes tlhat were consfructed prior to 1978 <br /> Phane: G -�l 7 . 790 {office) 7e '.3`j/•S�.6 (eeffp <br /> Mailing Address; � �. � � City:�S�� ZIP: C` <br /> �?�—.— ��� <br /> Contact Person: �����`��rh U-� Applicant i�--E-�rttrac o { Homeowner (Cirde One) <br /> Email and/or Fax f'��r..�SC�-i �'��>/� P_,��Lv/� 76��t jj• �"'�1�� <br /> PROPERTY OW ER I FORMAT ON: <br /> Name: � �� <br /> Phone(day}: <br /> Address: � «/ City�'�-�C�y�p ZIP: S.�S�+ <br /> Email and/or Fax <br /> PROJECT iNF RMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑Fire Damage MCWD review&permits: <br /> fvlinnehaha Creek Watershed District(MCWD} <br /> ❑Re-roof,asphal ❑ Repair ❑5torm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other( pecify) ❑Siding ❑Other:(specify} Fax: 952-471-0682 <br /> �indow(s) www-minnehahacreek.orq <br /> Overal{ Praject escrip#ion: .� � � L J� �7� �,� ,�Z- <br /> Estimated Cons ruction Va uati n of Project{excEuding land) $ �'��;�: (� <br /> APPLICANT A KNOWLEDGEMENT: <br /> • Agrees to rovide all information required or requested by the Building Department; <br /> • Certifies t at the information supplied is trve and correct to the best of his/her knowledge. The applicant recognizes that fhey <br /> are solely esponsible for submitting a complete application being aware that upon failure to do so,the staff has no alternative <br /> but to reje t it untll it is complete; <br /> • Some or I o#the information that you are asked to provide on this application is classified by State law as either private or <br /> confidenti I. Pri te data is informaYion which generally cannat be given to the public but can be given to the subject of the <br /> data. Co fidenti I data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose a d inte ded use of this information is to annually update our records and records of ather governmental agencies <br /> re uired b law. f ou refuse to suppEy the' ,rma' n,the a lication ma not be issued. <br /> Applicant's Signa re: . � � Date: c� •��°%�' <br /> Last Updated: 08-09- 011 <br /> I ,�/ /� <br />