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+ ��������� �����y ��a�e �� <br /> Gity of Qrono <br /> Buitding Permit Application for lViaintenance / Replacement / Renovatian <br /> {No structural expansion. {Jnly windaws, doors, siding, re-roof, etc.) <br /> _— <br /> ` ��`- MailnTg Address: Permit number: �3 -Qd � <br /> � � ' V�� PO Box 66 — <br /> `�s C stal Bay, MN 55323-0066 Date received: 5-� ��� <br /> � J `' � !` Street Address: Received by: __________ <br /> l. � � �/ 2750 Kelley Parkway Pian review fee: <br /> `' � Orono, MN 55356 1, <br /> ,\ !^ih E�,��/ <br /> - Total Fee:iv�� 8 3, � <br /> �.._� . <br /> Main: 952-249-4600 Fax 952-249-46�6 y�,�ry�;_=,;,i_Cron��rnn��s / <br /> This application for must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �Q�Q �t(`(� �/ �(!� � Qrbii/Q <br /> Will this be a Parade of Homes, Remodelsrs howcase Home or other Display Home? ❑Yes No <br /> If yes.a special event permii is required with Police Department and City Counci!approva!60 days prior to the event. Shutlle bus service wrtl be <br /> required unless applicant demonstrates sufircient o»-sife parking is available. Non-pen»rtted events wiH not be alJowed. <br /> CONTRACTOR 1 APPLICAN7 INFQRMATIt�N: <br /> Name: �'SE �" pr�j <br /> State License# � Expiration Date: ,� ( <br /> Lead Certification Number: � ._ Expiration Date: � j�- Q <br /> (foi work on homes thaf were constructed prior to 1978 <br /> Phone: (cell) ( 3$g' $�;"" (office) / `3s'�'-= � <br /> Maiiing Address: L( �l���` j� City: ZIP: f� <br /> Contact Person: �'( ��� Applicant is: Contract / Homeowner �ci«�eo�e> <br /> Email andlor Fax: �1�.�r ��jts" ��j��p <br /> PROPERTY(3WNER I RWIATION: 6���' '��t+� ��/�`'�� d�..� <br /> Name: e7C �� � c/ �T "� Q�. <br /> Phone(day): - s' .- <br /> Address: City� ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Ouerall ro�ect description: <br /> i Type of Project: Any earth movement may also require <br /> ( ❑Door(s} ❑Remodel ❑ Fire Damage MCWD review&permits: <br /> l�Re-roof,asphalt ❑Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202.Minnetonka Blvd� <br /> � ❑Re-roof,cedar ❑ Restaration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) ❑Siding ❑Other: (specify) ,.-- Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(S) y�nvtiv_rni_}r�ehahacreek.o_q <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplietl is true and correct to the best of hislher knowledge. The applicant recognizes that they are <br /> solefy responsible for submitting a complete application being aware that upon failure to do so, the staff tras no alternative but to <br /> 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 private or <br /> confidentiaf. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which gener I!y nnot be given to either the public or the subject of the data. Qur purpose and <br /> intended use of this inf mation i to a a�l date aur rF:cords and records of other governmental agencies required by law. If <br /> ou refuse to su f t inf m n i fon may not be issued. <br /> Applicant's Signature: Date: ��I��� <br /> Owner's Signature: Date: <br /> Last Update.d:03ld6l2013 <br /> _ . _ _ <br />