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City of Orona <br /> �������� <br /> ui ing Permifi Application for IUlaintenance f Replacement/ Remodel_ I�`; ',� „" ""'�I qNLY <br /> (i.e, windows, doors, siding, re-roof, etc. —NO STRUCTURAL EKPANSION) <br /> A� Marling Address: Pert7��t nu�'1b�P � �L�... <br /> �`��V� PO Box 66 ���� �.,, . <br /> ��: i i�.pii' �i . <br /> Crystal Bay, MN 55323-Ob66 Date received , ': _ <br /> I�E��iVed by `,: r, ;: :;:,. : <br /> ,� � Street AddrpSS: , <br /> ti�, �� z750 Kelley Parkway plari r�vl�W f e� � <br /> � Orono,MN 55356 <br /> ,��r,slJc1� ��.1r.i ki, ,�'�'� ' <br /> r...�,,,,,._ ��Q�����'�i.:"„ )� � <br /> Main: 952�249-46Q0 Fax: 952-249-4616 www.ci.orono�us ' U ! , , <br /> , <br /> This appllcation form must be completed in full and all required informatfon muSt e submitted, <br /> Incamplete applicatians will be returned. (P182s9 print) <br /> GENER�4L INFOFZMATION: <br /> Job Site Address: (`} ' � �f �'��_� <br /> Will this be a Parade pf Homes, Remode rs Showca ome or ot er Oisplay Home. Yes No <br /> 1�y�s, a spodal�venr parm;r is requrred wlth Polfce aepartment snU City Gouncll approval 60 days prior fo the evgnt. Shutf�e bus servlce w11!be <br /> requ�red uMoss appfrcant dsmonatra�es sr�ttic�enl on•sito parkirrg rs aveifeb�e. Non-perm4fed aven(s w;ll noi!�e allewed. <br /> CdNTRACTOR/APPLiCANT INFdRMATIQN: <br /> Name: � �- <br /> State License # �-�g� Expiration Date: ;��,)� �� <br /> Lead Certification Number: � ^ � �, �.�- �xpiration Date: $''����`�7(e <br /> {for work on homes thgt were construcied prior to 78 <br /> Phone: (cell) (office)'�(�3--'JS�'�?�,��.e,w'�.,S� Y m� � <br /> Malling Address: � !a� City: �� �IP: ��"7 <br /> ContaCt Pgtson: �� � Applicant Os: pntraCtp Homeowner (Clrcle One) <br /> Email and/or Fax: � � �� _ <br /> t <br /> PR�PERTY OWNER INF��tMATION: <br /> Name: ,.�0�111 '� 1�.1�n . V �l <br /> Phone(day): a.� f_.(�'� L-r��.�'tv�.ilr��td( f'� <br /> Address; �ayp p�bti,,,�,� C€ty: � � Zlp; �jS,3� <br /> Emaif andlqr Fax: <br /> � � � <br /> PROJECT fNF�RMATION: Overall ra'ect descri tion: } ���e <br /> Type of Project: Any earth movement ma also require��� <br /> ❑ Do s MGWD review&permits: ' <br /> r( ) � Remodel ❑ Fire D�mage <br /> Re-roaf, asphalt �Repeir ❑Storm Damage � Minnehaha Creek Watershed District(MCW D) <br /> k f� Re-roof,cedar O Restoration I 15320 Minnetonka Blvd <br /> f=1 water Damage Mlnnetonka,MN 55345 <br /> ❑ Re-roof,other s oclf Phane: 952-471-059p <br /> f P Y) [' Siding �Othgr�(specffy) Fax: 952-471-0682 <br /> ❑Window(S) www,minnqh�haCfe�,.orq <br /> �stima#ed Gonstruction Valuatiort of ProJect(excfuding land) $ <br /> APPLICANT ACFfNOWLEDGEM�N1': <br /> . Agrees to providc au information required or requested by the 8uilding Department <br /> • Certif��s that the information supplied is true and correct to the best of hlslher knowledge_ The appllcant recognizes th�t they are <br /> solely r�spvns�ble for submitting a com�lete application befng awsre that upan failure to do so, the staff has no �Iternati�e but to <br /> reject it untii it�s complete; <br /> • Some or all of Che Information that you are asked to provide on this application is classlifed by Stato law as eit)ier private or <br /> confidential. Prl+�ate data is information which generally cannot be given to thr,puplic but can be given ta the subJect of the data. <br /> Cr�nfidential data Is inform�tian which generelly eannvt be given Eo eithgr fhe public or tt�a subject vf the dat2. Our purpose and <br /> intanded use of this inform�tion Is to annuafly update our recards and records of other govornmental agencies required by f�w, If <br /> ou re{use to su I the Information,the a licatlon ma nat bs issued. <br /> �' <br /> ApplicanYs Sign�ture:G.�� �-��� pate: <br /> dwner's Signature: , _ Date: <br /> l.ast Updetetl:donuary 7.016 <br />