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To: Png`2 of 3 ZO'IZ-'1Z-'17 '17:SO:OZ (GMT) From: Apex Enargy Solutions <br /> l i <br /> C�ty af Orono <br /> Building Permit Apptication for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> _ —�:`� Mailing Address: pEnnit nut�►ber, �� -- �� <br /> � 0,�. PO Box 66 <br /> I,� � Crystal Bay,MN 55323-0066 Dat�receiVed_ �o�. � — r�-� ` <br /> (��� � Recei��ci by: <br /> a � , ,� ,�J Street Addrsss: <br /> `,'�'�, ' � G� 2750 Kelley Farkway Plan review fee: <br /> ?�.E$�o8�/ Orono, MN 55356 <br /> -_--- Tt�tal�e�: �j�, <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.or�no.mn.Us ���' � <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GEN RAL INFORMATION: /� <br /> Jab iteAddress: q�0 F�QNDACE �io�Q GL��� <br /> Will is be a Parade of Homes, Remodeiers Showcase Home or other Display Home? Yes No <br /> li s,a specia/everrt permit is required with Police Deparfinent and City Council approva/60 days prior to the event Shuttle bus service will be <br /> required unless applicent demonstrates suffm.ient on-sife parking is available. Non-perm7tfed events will not be a/lowed. <br /> CON RACTOR/APPLICANT INFORMATION: <br /> Nam : �}PUt �ivfRby Sac��'c�s c��/Y1in:n,�w"''N-, .�',vt._ <br /> State License# S�P�C�/�C.r� ��rv'TXi�1e�¢ t�1c�Pf'idJ Expiration Date: <br /> ----- <br /> Lead ertification Number: ��f/}��'� �i�y� �-/ Expiration Date: ,$' y' .7�/�'" <br /> (f work on homes fhat were constructed prior to 19T8 <br /> Phon : �,a 1^Fr 8b'^ Z 73`� {office) �/2-`7/p-.7Sa?fd (cell) <br /> Maili g Address: ��oo /Vo2�t�C� CRwf f3��a, S��" �r2n City: �vomi�6•rc.0 ZIP: ,s'yf�'7 <br /> Con �ct Person: C,:.�R�st'�Ay�,Q �tietc�i2 Applicant is: ctor / Homeowner (Circle One) <br /> Emai and/or Fax: t�'fr�¢�. �Q l4r C� �r�ftct i�: �'�rK ��c': �S/�- 3oS � b�/S/ <br /> PRORERTY OWNER INFORMATIO�: <br /> Name: ��t� Ftn,p F�na�cR�,c�� <br /> Phone (daY): �b5�- ��b�- ;��'] Cwoa�r� <br /> Addr �SJ ,��'rtNL�C� �o.�G �i.�E3T C�tY� t7�1oND ZIP: ,��Q� <br /> Emai�and/or Fax = _ _ <br /> PROJECT IfVFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ❑Remodel ❑Fire Oamage MCWD review$permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(specifyr) ❑Siding ❑Other.(specify) Fax: 952-471-0682 <br /> [�Window(s) www,minnehahacreek.oru <br /> Overall Project Description: R�Pu�t. if wrruDc�:.s — F�Crs�rivi DP�i�vEs <br /> Estimated Construction Valuation of Project(excluding land) $ �;y7� <br /> APPUCANT ACKNOWLEDGEMENT: <br /> • Agrees to provide alt 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 applicant revognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staif has no altemative <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 private or <br /> confidential. Private data is information which generally cannot be given to the public hut can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either ths public or the subject of the data. Our <br /> purpose end intended use of this information is to annually update our records and records of other 9ovemmental agencies <br /> re uired b law. If ou refuse to su I the infonnation e a lication ma not be issued. <br /> v/ f���� <br /> Appli nt's Signature: ` f�'�-- Date: <br />