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City af �rona <br /> B�uilding Permit Application far Maintenance / F2ep�acement I Renovation <br /> (Na structural expansion. bnly windows, doors, siding, re-roaf, etc.) <br /> ���0 Mailii�y Address: �ermit nuYnbeC: P4-1,l , � � <br /> PO Box 6G <br /> Crystal Say, MN 55323-0088 Date received: �—� ��, <br /> Sfreet Address: Rece�v�d[iy. � <br /> �� ��°`' 2750 Keiley ParkwaY Plan review fiae: <br /> Orono, MN 55356 <br /> � s�lo�`�' Total Fse: , (�g,�j <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed In full and afl required Information must be submitte . <br /> Incomplete applications will be�returned. (Please print) <br /> GENERAL 1NFORMATION: <br /> Job Site Address: I(IS ��ov✓,rt Q .S <br /> W111 th[s be a Parade of Homes,Remodelers Showcase Home or other Uisplay Home? Yes No <br /> !f yes.a specfal event permlt is required with Polrce Depertment and City Council approva!60 days prior to the event. Shuttle bus service wr�l be <br /> reqirlred unfess appllcant demanstrares suKicienf onslte parking ls avaflable. Non-permrtted events wil!not be a!lowed. <br /> CCINTRAGTQR I APPLI�QNT INFQRM�4TI N: <br /> Name: W� d�,�/ ��,{, <br /> State License# Bc 66S 3q9' Expiration Date: 3 3� ! <br /> L�ad Certification Number: �/�-r_123125..r Explratlon Date: 4 f <br /> (for work on home.s that ware construcbed prior fo 1978 <br /> Phone: (cell) �b3) �3�� ��� (���a �7`3)S�-Z 77.5 <br /> Mailing Address: (,(;�wr�,r (,� N ��tY� (�� wtou� Z�p' $-,�4-4� <br /> Contact Person: �yt u Applicant is: ontractor / Homeowner �c�«ia o�e� <br /> Email and/pr Fax: QI1N R�P�{�wi K ow�uV �T r°'� RSz��„�.�H l H� <br /> PRdPERTY OWN�R IN�ORMATION: <br /> Name� Y,k�'1 Coo�G� <br /> Phone(daY): bl2 2d - D(ol �� ------ — <br /> Address: (1 15 Br�wv� . S city: ��wo zIP:.�.��� <br /> Email and/or Fax: <br /> 0��:.� r� , t.St� x,�d x�$ ��t v. � . <br /> PROJECT [NFORMATIQN: Qverell ra�ect descri tion: � Sli 3��� Z'�wi►+atow +� �B'x�F2�� S+K t r,aSe.�'f` <br /> Type af Project: Any earth movement may also requlre <br /> ❑Door(s) ❑Ramodel ❑ Fire Damage MCWD review 8 permits: <br /> Re-roof,as halt Re air Minnehaha Creek Watershed District(MCWD) <br /> ❑ p � p ❑Storm Damage - 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar �Restoratian ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other: (specify) Phane= 552-471-0590 <br /> Fax: 952-471-Q682 <br /> (�Wihdow(s) e��R'f� www_minn h h r <br /> Estimated Construction Valuation of project(excEuding land) $ 2.�100.0 <br /> , <br /> APPLICANT ACKNOWLEDG�M�NI": <br /> • P�grees to provide all information required or requestad by the Building DeparCment; <br /> • Certifies tlla4 the Information supplied is tn,e and correct to the best of hislher knowledge. The applieant recognizes that they are <br /> solely responsible fpr submitting a complete applicati�n being aware that upon failure to do so, the staFf has no alternative but to <br /> reJect it unUl It Is compfete; <br /> • Some or all of the information that you sre asked ta provide on this appEication is classifled by St�te I�w as either private ar <br /> confidential. Private data Is information which generaffy cannot be given to the public but can be given tv the subject of the data. <br /> Confldentlal daYe is information which gen�rally cannot be g(ven to either the pubEic or the subject of the data. Our purpose and <br /> intended use of this ininrmation is to annually updete our re�ords and records of oth�9r governmentsl agencies required hy law, If <br /> ou refuse to su I the inf tlon the a�pli ma not be issued. <br /> AppEicanYs Signature: Date: � � <br /> awner's Signature: „ D�te: <br /> Last Upda#ed:�3l06l2013 <br />