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City of Qronc� <br /> Building Permit Application for Maintenance / Replacemen# I Renovation <br /> (No structural expansion. Only windows, daors, siding, re-rovf, �tc.) <br /> ��. y Mailing Address: Permit number. 3 —(Q �5 <br /> ���0 _ PO Bax fi6 <br /> Crystal Bay, MN 55323-0068 Date recelved: 9'�� -. <br /> „ti Stroet Address: Received by.. • � <br /> y � 2750 Kelle Parkwa <br /> � � y y Plan revfew fae: <br /> � <br /> �' Orono, MN 55356 <br /> l�'��sHa�. Total Fee: , / I. G/ �_ <br /> Main: 952-249-46a0 �ax: 952-249-4618 www.ci.orono.mn.us <br /> This application form must be completed in full and all requirod Enformation muSt be submitted. <br /> Incomplete appllcations will be returned. (Ple�se pnnt) <br /> GENERAL INFORMATION. <br /> Job Site Address: 2�� � fl�.'� ��(CQ� <br /> Will this be a Parade of Homes, Remod rs Showc�se Home or other Display Hame? ❑Yes No <br /> Kyes,a speCra!event permftls requlred with Police Department anC Gity Co�mci!approval 60 days pr�or to fhe event. Shuttle Bus sanrice will be <br /> required unless appllcant demonsfrates suftCclenf onsite parking is avaifabla. Non-permitted events wll!not be allowed. <br /> CONTRACTOR I APPUCqNT INFORMATION: <br /> EVame: !�� w�kC�o�✓ �j�. <br /> State License# [ �(��3�� Expiratian Date: � �Z�� � <br /> Lead Certificatlon Number: (�J�-'��[7^2�)��� Expiration Date: �y�.�d('� <br /> (for v►rork on homes that wene construcfed prlor to 9978 <br /> Phane: (cell) �, ��.r � (offce) �,� ���(-Z7� � <br /> Malling Address: `(�� � i City: Ntvc,c,t�b� zlh� j�'� <br /> Contact Persqn: � � �.,,er Applicant is: ontr c or / Homeowner (Clrcle One) <br /> Email andJor Fax' ��r ����IA.Lj p��COn-�t .�jl, -�',�3--�-]S-�.���a <br /> PROPER7Y OWNE�NFOR�MlATI�N`�� <br /> Name: ` <br /> Phone (day)� � _� p��, <br /> Address: a, �12 u,C� City' ' Uy`O ,L/Zlp. � 7j,�� <br /> Email andlor Fax: _���b � � r� �p,�,.F� , �'p�r,•� <br /> PROJECT INFORMATION: O�erall ro'ecE description: <br /> Type of Projeet: Any earth movement may also requ�re <br /> ❑ Daor(s) [� Remadel 0 Fire D$mage <br /> MCWD review&permfts: <br /> Mlnnehaha Creek Watorshed Distrlct MCWD <br /> �]Re-roof,asphait ❑ Repgir ❑Storm Damage 18202 Minnetonka Blvd ( ) <br /> ❑ fte-roof,cedar ❑Ftestoration ❑Water Damage Deephaven,MN 55391 <br /> ❑ Re-roof,o�ther(spectfy) ❑Siding ❑Other: (specify) Phone: 952-47�1-0590 <br /> �Wlndaw(s) ��� �-([��� Fax_ 952-471-Q682 4 <br /> www.minnehahacreek.or <br /> �stimated Gottstruction Vafuatlon of Prqject(excluding land) $_�_dC�, CJO _.__ <br /> APPLICAN'�ACKNOW�EDGEMEN7: <br /> . Agrees to provide al!information required or requested by the Buiiding beparUnent; <br /> . Certifies that tha information supplied is true and correct to the best of his/h�r knowledge. The applicant recognizes that they are <br /> sofely responsible for submitting a complete application being aware that upon failure to do sa,the staff has no alternative but to <br /> rejecF it until it is Complete; <br /> • Some or al! of the informatlon th8t you are ask�d to provide on this &pplication is classlfed by State law as either priv�te or <br /> co�fidential. Private data Is information which generalfy cannot be given to the public but can be given to the subject of the data. <br /> Confidential data Is Irrformation which generally cannot be �iven to either the public or the subject of the data. Our purpose and <br /> Intended use of this informatfon is to annually update aur records and records of other govemmental agencies r�quired by law. lf <br /> ou refuse to su I the informatio the a licatlon ma not be issued_ <br /> ApplicanYs Signature� .�- Date: _ �_ r �Z•�(� <br /> Ownar's Signature: Date: <br /> Last Updated:o3JoBl2o7s <br />