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OcT, ?2. 2G16 12: �3PM � No, 3104 P, 1/1 <br /> � C��1 �v ��. Y <br /> erm�t A lication fof Main�e�ance 1 Re �acement! RemQdei Res�d�ntia,l pN � <br /> �� o rona <br /> . Building P ' pp p L..Y. <br /> (i.e.wir�dows, dovrs, sidir,�, re-rvof, etC.—N� STR!!�'�URAL �XPANSIO�!) <br /> � �OA k MaIlIPQ Boa 66 I Pefmit number ,;t� '" s �� / <br /> 1 __. . > <br /> VQ Crystal Bay, MN 55323-D066 Date;rec�iv�d '�► <br /> Street Add�ess: Fteceived by <br /> �. � 2750 Kelley Parkway PJ�n�revlev�(�a, +�-r. . <br /> `�� . tiv Orono,MN 55358 : �, ', <br /> ��kFSH06 �'ofal Fe� ,� 1: �' <br /> Main, 952-249�600 Fax; 952-249-4696 ww�H ci.orono.mn.us �(,'"J,-; ., _ <br /> This application form must be completed in full and alf required information must be submitted. <br /> Incomplete applications wlll be returned. (Please print <br /> G�NERAL INFOFiMATION• �7 � � �Q �I�����1 I � Ue <br /> Job Sit�Address: - rZ'�- + l� ��� — <br /> WIII thls be a Parade vf Homes,Remodelars Showcase ome or ofher Isplay Home? ❑Yes IVo <br /> fl yes,a special event perml�Is required with Police Depanm�nt and City Councll approva180 days pnor t�!he e�enf. ShutUe 6us servrce Will bn <br /> required Unless appficant demonsttstes suf�lGent on-srte parking is available. Non-permitted events wi11 not be allowed. <br /> CONTRACTORIAPPLICANT INFORMATlON: <br /> Name: ��irlL'.��� YI�S <br /> State Licanse# C,c� ' Expiratlon Date� g <br /> Lead Certification Number: `�(1�--� Expiration Date� <br /> (for work on homes that were constructed rlor to 1978 �7 g <br /> Phone: (cell) p (afFice) %`� ��� � � l c� <br /> Malling Address: (/ City� f ZIP� L ' <br /> Contact Person: �r Appficant is: Contractor / Homeowner �c�ra�o�e� <br /> Email and/or F�x: � � <br /> PROI'ERTY OWN�R INFORMATION: , <br /> Name; �� <br /> Phone(day): - �{ � <br /> � itY: �U Zlp: � � �j <br /> Address: r i� <br /> Email and/or Fax� <br /> PROJ�CT INFQRMATION: Overall pro'ect descri tion: <br /> 7ype of ProJect: Any earth movement may also require <br /> MCWD revlew 8 permits: <br /> � ppp�(�� [�Remodel ❑Fire damage <br /> ❑ae-roof,asphalt �Rapair []Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 95320 Minnetonka Blvd <br /> CI Rs-roof,cedar ❑Restoration ❑Water Damage Minnekonka,MN 55345 <br /> p Re-roof,ot�er(Spacliy) ❑Sidfng ❑Other.(specify) Phone: 952-a71-0590 <br /> r� Fax: 952-471-Ofi82 <br /> __ �4(iqdflw(s) _ C_-- _ Nnaw.minnehahacreek.orq <br /> Estimated Construcfion Valuatlon of Project{�xcluding land) $ <br /> APPLICANT ACKNOW��DGEMENT; <br /> . Agrees to provide all information required or requesled by the Suilding Departmenl; <br /> • Gertifies ihat the Information supplied is true and ccrrect to the best oF his/her knowledge_ "fhe applicant recognizes that they are <br /> solely responsible for submitting a completa application being aware lhat upon failure to do so, l`�a staff has no alternative but to <br /> reject it until it is complete; <br /> • Some ar all of the informati�n that you are asked to provide on this appllcalion is classified by State law as aither privaEe ar <br /> confidential. Private data is information which generally cannot be given to the public but ean be giv�n to the subject of the data. <br /> Confidantial data is]nforma�ion which generally eannot be given to either the public or the subjec�of�he data. our purpose and <br /> intended use of this information is io annually update our records and records of other governmental agencies required by law, 1f <br /> ou refuse to su I t Info ation,the a lication ma not be issued. <br /> App�icant's Signature: '` l.��ate� 1 <br /> Owner's Signature: pate: _ <br /> Lasl Updated:January 2016 <br />