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���y Qf �ro�o <br /> Buifding Permif Application for Maintenance / Ren�vation - <br /> (windows, cioors, siding, re-roof, etc.) <br /> MailingAddress: �j 1 , ��( <br /> �0,� PO Box oo Permitnumber. <br /> � ��\ Crystal Bay, MN 55323-0066 Qate received: '�D <br /> � ' <br /> �� ' �-� ,� Streef Address: Received.by: <br /> �;. <br /> ��n �'���Gti� 2750 Kelley Parkway Pfan review fee: <br /> t`�kEsxo4' Orono, MN 55356 <br /> Total Fee: �a�o��, a� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> incompfete appfications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ��t3/ �,(���� ��;�; �� � _ �v z.�;-�- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display ome? ❑ Yes No <br /> If yes, a special event permit is required with Police Departmenf and City Counci/approval 60 days prior to the event. Shutt/e bus service wil!be <br /> required unless applicant demonstrates sufficrent on-site parking is available. Non-permitted events wil/not be allowed. <br /> �C N RA�20f�/APPLICANT INFORM ION: / <br /> Name: . CC$7�� ��.,p�S'r(LctcT+e�-� <br /> State License # �L �j�,3 j3�� y� Expiration Qate: 3i � <br /> Lead Certificafion Number: (D g�j�cr _ � Expiration Date: � 7� /�' <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 3�- �r7�- ��v� (office) cell <br /> � ) <br /> Mailing Address: �'/c�s- ,f',v �: �,,rL 5T- City� � ��r � ��,� ZIP: S�`�� <br /> Contact Person: �-�L��� Applicant is: Contrac or / Homeowner (Circfe One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATIOf�: <br /> Name: -�1ONA•'�t��r-�J LC�=Oa�-'�1= <br /> Phone(day): • <br /> Address: ��O/ (,�JQS'i' ��C-�2,Jc�I-C�' /�/� City. ('�f� -.�n�-y{ ZIP: �j' <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel MCWD review&permits: <br /> ❑ Fire Qamage Minnehaha Creek Watershed District(MCWD) <br /> �Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Bfvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof, other s eci Phone: 952-471-Q590 <br /> ( p fy) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 <br /> ❑ Window(s) www.minnehahacreek.orq <br /> Overall Project Description: • (�-� Br�' � ���,�' <br /> Esfimated Construction Valuation of Project (excfuding fand) $ �a ���' <br /> APPLICANT ACKNOWl.EDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the informafion suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are sofely responsible for submitfing a complete app(icafion being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the informafion that you are asked to provide on this application is classified by State law as either private or <br /> confideniia(. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidenfial data is informafion which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse to su 'nformafion,the a iication ma not be issued. <br /> . __ 1 . <br /> ApplicanYs Signature: Date: �' �`���z— <br /> Last Updated: 08-Q9-2011 <br />