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Ci��r af �rono <br /> Building Permit App�[ca#ion #or IlAaintenance I Renova#ion <br /> (windows, doors, siding, re-raof, etc.) <br /> MalAng Addross: Permii number' �/�-- <br /> Q.�,Q,�.� PO 6ax 66 <br /> Crystal Bay, MN 55323-0066 D�te rec�lved: � - <br /> � Streef Addtess: Received by: <br /> �� � <br /> o�`� 2750 KsNey P�rlcway Plan revlew fee: <br /> ���ag2 Orono, MN 55356 <br /> Total Fee� ����� <br /> Maln: 952-249-�600 Fax: 952-248-4616 www.cf.orona.mn.us <br /> �'his appfication form rr�ust be completed in full and afl required lnformation must be submitted. : <br /> Incomplate applications will be retumed. (Please print) <br /> GEN�RAL INFORMATION: � f - C � ; ��r� � ��{�� <br /> Job Site Adcfress: W J �`, <br /> Wifl this be a Parade of Hames, Rerrtodelers Showcase eme or other Dlsplay Home"T � Y�s No <br /> /f yes,a specie!ev6nt pAm'rit fs requirr�d rvith PoJrce IIepartmerrt�nd Clty Council approval 6D day8 prlor to lhe�vent. ShutHe bus sen/iCe W/ll be <br /> required unless 8pp!lCant demonstrates scrtficienf onsife parking 1S avallable. Non-permitted aVents Wll/npt be allowed. <br /> C4NTRAGTOR/APPLICANT M�OI�MA'CION: <br /> Name: t`�tr�, a.� "A��trSe� <br /> State License# �,\3p�j S� � _ �xpiration Dat�: � �1'3 4 <br /> Lead Certification Number. �j�-S'� a�.a�3 �1 Expiration �ate: �()je,., <br /> (for work on homes H�at wene constructed prlor to 9978 - -- <br /> Phane: (05�� a t�y-�.o SS�Ar� (Qffce) (cell) <br /> Mailing Address: , j� "��• t�J� ---MC�tY��D ; �, Z1P: ar'"S I '3 <br /> Contact Person: Applicant is: n �or / Homeowner �c�rot@ o�e� <br /> Emai!and/or Fax: <br /> PRdP�RTY OWNER INFORMATfON: <br /> Name: �, �-� �, • <br /> Phone(day): ����j _�0� � <br /> Address� Jj� City: ZIP: <br /> Email and/or Fax <br /> PROJECT INF�RMATIQN: <br /> rype a�p�ge�: My earth movement m�y requlre <br /> � Door(s) ❑ Remodel ❑Fir�Damage MCWD revlew&pemnits� ' <br /> Minnehaha Creek Watershed Dlst�ict(MCWD) <br /> Q Re-roof,a�phalt ❑ Repair ❑Storm Damage 78202 Mlnnetonka Blvd <br /> ❑ R�roof,cedar ❑ ReStofation ❑Water Damage ��ephaven,MN 55391 <br /> PhOne: 952�79-0690 <br /> ❑Re-roof,other(�paciiy) ❑Siding �]Other: (specify) Fafc' 952-471-0882 <br /> �Window(s) www�3"►'�Innehahacreek.ora ' <br /> 4v�re11 Pro ect Descrip#ion: �acA � `�1:vti d0u�f 'Z 'o - � � � rh <br /> ��stimated G�nstruction V'aluatfon of Pro)ect(exclu ing lan ) $ a(� ��J Z-� _ ,,Q_�( ;��, �_� <br /> APP�.fCANT ACKNOWL,�DC�EMENT: <br /> � ��'� <br /> • Agrees to provfd�all infoRnation requir�d or requeated by the Bu��ding Department; <br /> . Certfies thaf the Informatian suppiied is true and correct to the basi of his/her knowledge. The eppficant recognizes that they <br /> are soleEy respdnstble fOr Submltting a complete application being aware that upon t�ilure ta do so, the sfaff hes no altemative <br /> but to reJect it until it is complete; - <br /> • Some or all of the information that you are asked to provide an this appllcatlon is classified by State I$w as eithe� prfvate or <br /> r,onfldenUal. Prfvate data is information which gener8ily cannot be glven to the publio but can be glven to the subject of ihe <br /> data. Canfldential data is infiormadon which generally cannot be given to either the publlc or the svbject of the'data. Our <br /> purpoee and intended use of this information 13 to annuelly updaie our rewrds �nd records of other govemment�l agenCips <br /> re ufred b law. If ou refuse to su 1 the inivrmation the a lication ma noi be issued. <br /> A�olicant's Sian�ture: � d��' /� ��� �'�"� <br />