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��� Ci�ty of Orono <br /> E�uilding Permit App�ication for Mai�ntenance / Renovation <br /> (windows, dOOrs, siding, re-roof, etc,) <br /> Mailing Addr�ss: F'ermit number' <br /> Q.�,O,�� PO Box BB <br /> � <br /> Crysta!Bay, MN 55323-0066 Dat�rQceived: <br /> � ��' � Street Address: Received by: __ _ _ _ <br /> 27501Celiey Parkway I'lan review fes' <br /> � o�,� Qrono, MN 55356 <br /> Totat�ee: <br /> Meln: 952-249-t►600 Fax: 952-249-�816 y�,v�,.ci.arano.rrzn_us <br /> 7his applicafion farm must be completed in fut! and aA required information must be submitted. <br /> Incomplete applications wlll be returned. (Pleas9 prinf) <br /> Job Sit�e Add eOSMATION: � 1��, � `��,���� �O 1 ��"` �O _ _I <br /> c�.�,� <br /> Wit1 this be a Parade of Homes, Remodelers Sho case Homa or ather Di�play Home? Yes No <br /> K yea,a specia!event permlt!s roqulred wlth Po!!ce Dapartment and Gity Councll epprova!BO days prior to the event. Shuttle bus servlce w!!I be <br /> ropull'gd unless aFRlrcant demonstrates suff'rcienY On-sKe parking is availatrfe. Non-permiKed 9venfs w111 npt be allowed. <br /> CONTRAC�'Of�/APPLICANT INFORMATION: <br /> Name: �+C�.u��a.\ ���-tr�er� _ <br /> State License# "�j�1�0`�g'3 Expiration Date: ��'3� <br /> LeBd Certification Number: (`,j�'�,� ��a$� -� Expiration Date: L(�15___ _ <br /> (fi�r worlr on hqmes thaf rvene constructed prior to 99r8 ��I <br /> Phone: �CS 1� o�(0�{-��0�` �Ar� (office) ( ) <br /> MailingAddress: 1Q'dD C . � `•G" WES�- C�tY�� ; f. Z1P: SSI 3 <br /> Contact pe�son: Applicant is: orrtra / Homeowner �ci�cfe 4ne� <br /> Ernail and/or Fax: � <br /> PR4PERTY OWNER tNFORMATION: <br /> Name: 1�G��0� rn0.C O • <br /> Phone (day): � _ )..Q s f <br /> Address: '� �,. City: Z!F': <br /> Email and/or Fax <br /> PROJECT 1NFQRMATION: <br /> 'iype af Project: My earth movement may requlre <br /> �'Door(s) ❑Remodel ❑Fire Damage MCWD revEew&permfts: <br /> Minnehaha Creek Watershed Distri�t(MCWD) <br /> ❑ R�roof,asph8lt ❑ Repalr ❑Storm Damage 1$202 Minnetonka Blvd <br /> [] Re-roof,cedar ❑ Restor�ti0n ❑Wafer Damage De�ph�ven, MN 55391 <br /> Phane_ 952-471-Q590 <br /> Q Ft�roof,oth$r(speelry) []SEdtng Q Other:(spscif}r) Fax: 952�71-0882 <br /> � �'Wndow(s} www.minnehahacr�ek.or� <br /> Over'all Pro eot Description: q � c.,�S� Y� G`C �✓\ <br /> �stimated Constructfon Valuation of Projecf(excludin land $ �� 3'� ; <br /> ���r�� <br /> APPLICANT AGKNpW�,EDGEMENT: `�1 <br /> • Agreas to provlde aE!information raquired or requested by the Building Department; <br /> • Gertifies tttat the information supplied is true and correct to the best of hisJher knowiedge_ The appiEcant recognizes that thsy <br /> af9 SQI2iy CeSpOnSible for submitting a compiete application being aware that upan f8ilure to do so, the staff has no altemative <br /> but to rejsct�t until i�is complele; <br /> • Some or ail pf th� information that you are asked to pmvide an this �pp(icat�on is classi�ed by State law as e�her prlvate or <br /> corafidential. 1'rlYate d8t8 is Inipmlation whlch generally cannot be given to the public but can be g�ven to the subJect of the <br /> data. Confidential data is information whlch generally cannot b� given ta elther the pubfic or the subjeCt of t1°ie data. Our <br /> purpose and infended use of th{s Informatlon is to annually update our r�Cprds and records ofi other govemmental agencles <br /> re uired b law. !f u refuse to su 1 the informatlon the a lication ma nof be isaued. <br /> ADoEicant's Sianature: Date: �Q �U ! y <br /> � <br />