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CEfy af Q�o�o <br /> _ Buifding Permit Appl�ca�ion for Nlaintenance / Renovatio� � D���� <br /> + (windows, doors, siding, re-rovf, etc.) / <br /> �► M,ailing Address: /� <br /> /�v d,� `w;.Z .��-� � �� PO Box 66 Permit number. G�Q( _ ���p <br /> , O 0 ��>�. Crystal Bay, MN 55323-0066 Date received: — ' <br /> � -� <br /> ° Received by: � <br /> ' � �r � � � Street Address: <br /> �� � t���l; � �� <br /> �,� 2750 Kelley Parkway Plan review fee: (��$+�� ��- � <br /> �q'kESH��� Orono, MN 55356 <br /> aof3- ooa6�- <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incompfete appfications will be returned. (Please print) <br /> GcNERAL INFORMATION: <br /> Job Site Address: �',��� �_� �c ��(`� �'t��.vv j�,�f�.�� <br /> Will this be a Parade of Homes, Remodefers Showcase Home or other Display Home? ❑ Yes �o <br /> !f yes, a specia/event perrttit is required with Pofice Department and City Counci!approval 60 days prior to the event. Shuttle bus se�vice wil!be <br /> required unless applicant demonsfrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATIOI�: <br /> Name: � }-�� �:� �'��.,-V(C:.s <br /> State License # [� �-,2/6� Expiration Qate: � . 3 j-- 1� <br /> Lead Certificafion Number: Expiration Qate: <br /> (for work on homes that were constructed prior to 1978 -- <br /> Phone: (ofiice) (cell) <br /> Maiiing Address: �v���•,,�, � City: �,,��y�,/K,,�� ZIP: 5�'z��5� <br /> Contact Person: ��1�� Appficant is: Contracto / Homeowner (Circle One) <br /> Email and/or Fax: �;G;�� ���j��`� /��,,,�a� ,��„�� � , ��� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �Tlt D�NS�= <br /> Phone(day): �i Z� 3�l T _ �3�r�, • <br /> Address: ��� ��,�,n�� City: ���c �,•`; ZIP: <br /> Email and/or Fax <br /> PROJcCT INFORMATION: �'�I���_ �x� '� ��� �- ��x�� W , -��, P`�c � �v,y�. iqw�.,� �2c <br /> Type of Project: ' Any earth movement may require �� <br /> ❑ Door(s) �Remodel ❑ Fire Damage � <br /> MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) �• <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Qamage 18202 Minnetonka Blvd � <br /> ❑ Re-roof, cedar Dee haven, MN 55391 G <br /> ❑ Restoration ❑Water Damage p <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) �] Siding ❑ Other: (specify) i Fax: 952-471-0682 � <br /> ❑Window(s) i www.minnehahacreek.ora �, <br /> �: <br /> Overall Project Description: <br /> Estimated Construction Vafuation of Project (exciuding land) $ (�d�,�,x� ---_ � <br /> / � <br /> APPLICANT ACKN�WLEDGEMENT: ] <br /> • Agrees to provide all information required or requested by the Building Department; �/ <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The appficant recognizes that they � t� <br /> are solely responsible for submitting a compiete application being aware that upon failure to do so, the staff has no alternative � � <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 privaie or <br /> confidenfial. Private data is information which generally cannot be given to the pub(ic but can be given to the subiect of the i <br /> da;a. Confidenfial data is information which generalfy cannot be given to either the public or the subjec'c of tne data. Our <br /> j purpose and intended use of this information is to annually update our records and records of other governmental agencies I <br /> � required bv taw. If you refuse to supply the information the aqpfication mav not be issuPd <br /> � � <br /> ApplicanYs Signature: � f �.✓��_--� Date: � 1— �y - � <br /> Last Updated: 08-09-2011 <br />