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���y of Q��ono <br /> €�uilc�ing Pe�mit App�icafio� for IV�ainter�ance / Rer��vation <br /> (windows, doors, sidic�g, re-raof, etc.) <br /> M,ailing Address: 'n Permit number. 0�0/ -l���/ � <br /> �,�,j�. PO Box 66 y.��+'�� 'L <br /> /� � �� Crystal Bay, MN 55323-0066 Date received: 7—Z-'/�j <br /> � S3 1 <br /> �'��".� a Receivedby: ,�S ` <br /> \� Q���� �, Stre.,f Address: <br /> ��nt ' �'���,� 2750 Kelley Parkway \ Plan reviewfee: <br /> �s� � Orono, MN 55356 � " <br /> ESFID `;,.- <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 wwv��.ci.orono.rnn.us <br /> This application form must be completed in full anci all required information must be submitted. <br /> fncompfete appfications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> � �� ��. <br /> Job Site Address: �� � � % � - ,���-y'y <-_ .._ ,� .���_ <br /> Will this be a Parade of Nom s, Remodelers Sho�ase HomE� or other Dispfay Home? ❑ Yes ❑ No <br /> lfyes, a specia!evenf permit is required with Police Department and City Cc4ncil approval 60 days prior to the event. Shuttle bus service wilf be <br /> required unless applicant demortstrates sufficienf on-site parking is avaifable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPL NT,INFOR 10 : <br /> Name: / /� �' ,� _ _ <br /> >ItI.K ✓�-' L'L-� • y� <br /> State License # Expir�fion Qate: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes f at were constructed prior to 1978 <br /> Phone: 2 - /C�'��i ' �; �',3-� �officej (cell) <br /> Maifing Address: � S��/a� � ��'�f�,s��r� � City. �'�� ZIP: <`�;S• y�' <br /> Contact Person: �, �. �7.�� ,`� s._,_, Appiicant is: Contractor / Homeowner (CircleOne) <br /> Email and/or Fax: <br /> PROPE2TY OWNER INFORMATIO i <br /> Name: �� C�- .��.�'� ,(. �.. c���— <br /> Phone(day): � t Z � �e�h � G=�'���.� ' <br /> Address: / ��/r � � �'� ��— City: ��" � ZIP: � .� --� �l/� <br /> Email and/or Fax <br /> PROJECT INFG►P.MATION: <br /> Type of Project: � Any earth movement may require <br /> ❑ Door(s) � ❑ Remodel ❑ Fire Damage � MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Qamage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damae�e Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (speciry) Fax: 952-471-0682 <br /> I , <br /> � ❑Window(s) _ www.minnehahacreek.orq <br /> � <br /> Overall Project Description: <br /> _Estimated Construction Valuation of Project (exciuding fand) $ � "L S!`�-` <br /> APPLICANT ACKNOWLEDGEMENT: <br /> i • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the informafion supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they � <br /> are solely responsible for submitting a compfete applicaiion heing aware that upon failure to do so, the staff has no aliernative <br /> but to reject it until it is complete; <br /> � • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confideniial. Private data is information which en , Ily cannot be given to the pubiic but can be given to the subject of the i <br /> I data. Confidential data is 'rfformation whic , Ily cannot be given to either the public or the subject of tne data. Our I <br /> j purpose and intended e of this inforrrya annually update our records and records of other govemmental agencies i <br /> � re uired bv law. If o refuse to su i h ' ' r afion.the ao Iication mav not be issued. <br /> , _ <br /> ApplicanYs Signature: �� �� ,,�v� � -� Date: i �' � � <br /> / ` � � <br /> _ast Updated: 08-09-2011 <br />