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. � �i�y of Qro�o <br /> Bu�l�ing Permit Appiication for Nlainter�ance / Renovatio� <br /> (windows, doors, siding, re-ro�f, etc.} <br /> Mailing Address: ; D/a_�� <br /> ���Q,� PO Box 66 Permit number: � �� <br /> ��.�„ O <br /> Crystal Bay, MN 55323-0066 i Date received: 7"'��� <br /> �a �-`.'�, �, ; Street Address: Received by: <br /> \ ��^�; <br /> \�".� �'�:,�;�,,, G/ 2750 Kelley Parkway Pfan review fee: _ � ,3�0� $ <br /> '��s.g�s�o�,� Orono, MN 55356 p'?p/ a -007 a <br /> Total Fee: <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 /> fncompfete appfications will be returned. (Please print) <br /> GEN�RAL INFORMATION: <br /> Job Site Address �a�Q -��X ��fo�,� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a specia/event permit rs required with Po(ice Department and City Council app;oval 60 days prior to fhe event. Shuttle bus service wil!be <br /> required unless app(rcant demonstrates suffcient on-site parking rs avai/able. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATIOI�: <br /> Name: � - � U, ' <br /> State License # p Expiration Date: �3 • <br /> Lead Certification Number: A 7"--�� ��' Expiration Date: �;, p <br /> (for work on homes that were constructed prior fo 1978 <br /> Phone: j _ ' �--� �(o� (office) (cell) <br /> Maifing Address: � City: ' ZIP: <br /> Contact Person: �r. App(icant is: Contractor Hom owner Circle e� <br /> Email and/or Fax: �, , � �_• ; Co� � � ��• <br /> PROPERTY OWNER INFORMATION: <br /> tV a m e: �-c,(Yln �F NVY�2/S I� I U��Gt/1 <br /> Phone(day): • <br /> Address: 2�SO ��X �'�1� c�ty: �YLfjr�U ziP: �N 553'� <br /> Email and/or Fax <br /> PROJc.CT INFORMATION: <br /> Type of Project: � Any earth movement may require <br /> MCWD review& ermits: � <br /> ❑ I�oor(s) �,�'Remodel ❑ Fire Qamage P <br /> 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: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) � Fax: 952-471-0682 <br /> ❑ Window(s) www.minnehahacreek.orq <br /> . � <br /> Overall Project Description: � aF -�. � _ S <br /> Estimated Construction Valuation of Project (ex luding fand) � �n 000 N <br /> APPLICAI�T ACKNOWLEDGEMENT: <br /> '� • Agrees to provide all information required or requested by the Building Department; <br /> � • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they � <br /> are soiely responsible for submitting a compfete applicaiion being aware that upon failure to do so, tne 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 cfassified by State !aw as either privaie or � <br /> confidential. Private data is intormation which generalfy cannot be given to the pubfic but can be given to the subject of the I <br /> data. Confidential data is information 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 /> required by law. If you refuse to� .i€+�mr�tion f�ie a�p(ii tion may not be issued j� , <br /> ,, - -�--- _. <br /> ,s � .,� , u...s_ U <br /> ,_� -�—=-• .• <br /> Applicant's Signature: `� �,,,� � � Date: � �O � <br /> !ast Updated: 08-09-2011 � <br />