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C�ty af �rano <br /> � Building Permit Applic�tion for Maintenance 1 Renovation <br /> ' (windows, doors, siding, re�roof, etc.) <br /> Malling Addr�ss: Permit number: �,/', '1:, ��.�-�' � <br /> . �.�,C�,�.� PO Sox 66 y <br /> Crystal B�y, MN 55323-0066 Date received: � <br /> Sfreet Address. Received by. ��' u <br /> 275Q Keiley Perkway Plan rev{ew fee: � <br /> Orono, MN 55356 —� <br /> ��o�' I <br /> Total Fee: � �; �;� ,�1 <br /> Main: 952-249-4600 F�: 9�v2-249-d616 wtn�w.ci.orona.mn_us - � � <br /> This applicat€on form must be corrzpleted in full and a(1 required infarmatian must be submitted. <br /> Incomplete appllcatlorts will be returned. (Please print) <br /> GElVE12AL I(�FaRMATION: ��� , � t �Q� ����� <br /> Job Site Address: <br /> Will this be a Parad�vf Homes, RemQdelers Showcase Home or other Display Home? [�Yes [] No <br /> !f yas,s specla!evenY perm#Is requlr�d wtth Police Depanment and GrYy Cpuncll approva!60 days prior to the evenf. Shuttle bUs s�t'IhCe W(11 be <br /> r�quired unle8s appJJCa»t demon5traies su(flcieni on�sife paricirrg is avarlab(e. Plon pennitted ev�nts wlll not 6s allowa�l. <br /> CONTRACTOR/APPLlCANT{N�ORMATION: <br /> Name: �'�-E.r�f.x,..'�a.1 �l 'AY�c��.'�Se� - - <br /> State Llcense# '�$C\30�f$3 Expiration Date: '?j��� <br /> Lead Certiilcatlon Number� �j��� o`I��-c�`�� +.l, --- --- ExPiration Date: ��15 - --- <br /> (far work on homes Hrat rvere constructed prinr to i978 <br /> Phone: (e�l— r�i ��O$�- �sc r. (office) (cell) <br /> Maifing i4ddress: tq� C . � '�C,�, ���- City: � �, 21P: S�� 3 <br /> Contact Per'sor►: Appllcant Is o tractor / Hpmeowner �ci�ie ona� <br /> Email andlor Fax: <br /> PROPERTI(OWNER IN�ORMATION: <br /> Name: {j-�'�,V..�� '`�ti ;[},�r�SDYI <br /> Phone(daY)' RS � - � 3 <br /> Address: (S; � , � City: ZIP: <br /> Email and/or Fax <br /> PROJECT lNF�RMA'TION: <br /> Type of Project: My�arth mev�ma+nt may require <br /> ❑Door(s) ❑ Remnde! �j Fire Damage MCWD revfew&parmlfs; <br /> Minnehahs Creek Watershed Dlstri�t(MCWD) <br /> ❑Re-roof, asphelt ❑ R�pair ❑Storm Damaga 18202 Minnatonka Blvd <br /> ❑ Re-roof,cedar �Restnratlan []Water Damage �e�Ph2ven,MN 55391 <br /> Phone: 852�71-0590 <br /> []R�roof,o#her(apoclfy) ❑Siding �OkhQr_(spec4fy) Fax: 552�71-0682 <br /> �Window(s) �„��CQ. �a {�n W� w'�'�v.m:��habaG.reek.o[� <br /> �verall Project Descri�Elon: G�v -e��S��Q 4���'r� • <br /> , ---.._...__. __. <br /> Estimated Construction Valuatian of Project(excluding Eandj $ J q. DO <br /> AF'F'LICANT ACKNdWLEDGEM�NT: <br /> . i�grees to provide ali iniormatian requfred or requested by the�uilding Department; j <br /> - + Certlfles that the informati�n supplied [s true snd correct to the best of hislher knowiedge. Tha appiicanf recognizes that they <br /> are aolely responsible for submitting a campiete applfcatlan being awarsa that upon faiiure to do so, the s#aff has na altemative <br /> but to reject it until it is compEete; <br /> • Some or all of the information that you are ssked to provide on this appiicatian is classified by State Iaw�s e�ther private or <br /> Cfln�dentl�i. Private data is ini�a�rr►ation whiCh gG>nerally cannat be given to the p�blic but can be given #o the suhject of the <br /> data. Confldentlal data is infvrmatian which generally cannot be given to either the public ar the subject a� the data. Our <br /> purpose and intended use of this inf�orm�tion is to annually update our records and r�cards of other govemmen�tal agencies <br /> re u#red tr law. If ou r�fuse ta su i the irrformatlon the a llcatlon ma not be issued. <br /> AoDliCant's Sianature:� � �'� Date: ���/� <br />