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� City of Urano <br /> Buiiding Permit Applicatian far Maintenance / Renovatian <br /> (wirtdows, doors, siding, re-roof, etc,) <br /> ��� Malllp0 BWc 6fi• � I <br /> Permit number� �Q��-U � <br /> � � Crysf21 Bay, MN 55323-0066 Date received: �o —�.3 � <br /> � Sfreet Address: R�ceived hy. <br /> G� 27'50 Kelley Parkway Pian review fe�: __ <br /> ��� Orona, MN 55356 Q <br /> Totai�e�: � U. � <br /> Main: 952-249-4600 Fax: 952-249-4616 www_ci_arono.mn.us <br /> 7'his applicatian form must be comple�ed in full and al1 r�quired informatfon must be submitted. <br /> lncompl�ts applicatidns will be returned. (Please prinf) <br /> GENERAL INF4RMAT10N: <br /> Job Site Address: I�'�� C o�Car cl�c,,, . �-(-��,� <br /> Wili thls be a Parade ot Homes, Remodelers Showcase Home or other blspEay Mome? Y�s No <br /> X yna,a specia/event pe�T»Pt!S r6qulrgd wlth Pollce Depa�rnent and City CounaY spprovgl 80 days prlor to tire event. Shuttle bus servicc>w!!I be <br /> iequlred unfess applicant demonstn�f6s suH7clent pnsfte parking is available. Non-p�J'mftted 6v9nts wlJl not 8e alfowed. <br /> CONTRACT�R/APPL.lCAN71N�'QRMATIQN: <br /> Name: 1�-� � 'Av��xSer.7 <br /> __. _ <br /> State l.icense# C.��0�$ � _ Expirati�n aate: '��3� <br /> .� -- <br /> Lead Certificatian Number: �j�����.ag3 �� Expiwation Date: 4I t5 <br /> (1br wor�c on homes that w�Cons#ruct�ad pr,f'or to i978� <br /> Phone: 1D51� o�(�y-4 0$$' �ityAh (ofFlce) � (cell) - <br /> Maiiing Address: �• •• WES�{' City. � � ZIP� �S 1 � <br /> Contact Person: Appllcant Is: n r r / Homeowner (c���a ona� <br /> EmalE and/or Fax� <br /> PROPER7Y OWNER INFQRMATIQN: l, <br /> Narne: �L G��!: [� ►1 C>>��`�.. , <br /> Phone(day): '�. � - d p <br /> Address: �S; City' ZIP: <br /> Email and/or Fax ��� T <br /> PROJ�CT IN�ORMATiON: <br /> Type nf Projact: Arry earEh movement may requi�+e <br /> ❑ Door(s) ❑Remodet ❑Fire Damage M�p����F��^its: <br /> Mlnnehaha Creek Watershed Distrtct(MCWD) <br /> ❑Re-roof,asphalt �Repair ❑Siorm Damage 18202 Mlnnetonke Bl�d <br /> � R�roof,ceder ❑Restoration C]Water Dam2ge Q��p��v��.MN 5539� <br /> phone_ 952-471-0590 <br /> 0 R�roof,other(spectfy) ❑Sldfng [�Other. (sp�cify) Fax: 952r471-0fi82 <br /> indaw(s) wrwv.minnehehacreek.or� <br /> dverall Project Descri tion: 0. '� p W� � .� �l`Q� <br /> Estlmated Cvnstructinn Valuation of Project(exciuding land) � � $a QC) 0 <br /> � <br /> APPLICANT ACKNOWLEDG�MENT: <br /> • Agrees to provide all information raquireti Ot'requested by the Building Departm�nt; <br /> • Certi[ies that fhe Infarmatlan supplled Is true and carrect to the best af hfs/har knowledge. The 2pplic8ni recagnlzes fhet they <br /> are salely responsible for subm�tting a comp[ete applicatlon being eware that upon failure to do so, the siaff has no altemative <br /> but to re)ect it unbl it is oomplete; <br /> . Some or all ot the IMprmation that you are asked to provide on !ltis applicafion is c[essrffed by State faw as either prtvate or <br /> confidenti�l. Pn"vate data Es Infarmatlon whiah generally Ca�not be given to the public but can be give� ta th� Subject of ihe <br /> ciata_ Confidential deta is information which generally c8nnot be given to efther the public or the SubjeCt of the data. Our <br /> purpose and lntended use pf 4hls lnformatlon is to annually update our recorr�s and recards of other govemmen#af agencies <br /> re uired b law. If u refuse to su I the informatian,the a €ication ma not be Iss�ed. <br /> An�lEcant's Slanature: Date: ����'`�� j� <br />