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. � City of �rona <br /> �" Building Permit Application for Maintenance 1 Renovation .,��� <br /> (windows, doors, sidin�, re-roofi, etc. ��'�� <br /> Mailing Address: Permit number: 2C,' (J ��� �7 <br /> ��Q�� PO Box 66 J" -, _ �- <br /> Crystal Bay, MN 55323-0068 Dste r�c��ved: — .�� f � <br /> Recelved by. —� ' <br /> Stroef Address: <br /> � ' '' �� 2750 Kelley Parkway I�lan rewew f�ae� " <br /> � Orono,MN 55356 �j <br /> �� � 7otal Fee: G� � <br /> M2in: 952-249�800 <br /> Fax: 952-249-4616 _ci.o o.mn.0 '�( 1 , <br /> This applicatlon form must be completed in full and a11 required lnfarmation must be submitted. <br /> Incomplete applecatEons will be returned. (P/ease print) <br /> GEN�RAL,INFORM#ATIdN: , ��� � /' ���� ��; <br /> Job Site Addr�ss: � �J <br /> W1}f this be a Parade of Homes� Rerr�odelers Showcase Hort��ar other Display Home? ❑Ye� �10 <br /> M ygs,a speclel event pelmif is requirod wdh PoliC&,Oepartment and Crty COunci/approv2160 deys priqr to the ev�nf. ShUfile bus seNlC�wFll be <br /> requfrod unless applfcant demonStrates stlffk��nt on-s�e p8rlcing is dval/abfe. NOn-permrtted evenfs wil!not be allDwed. <br /> CONTRACTOR!APPLICANT INF�RMATIdN: <br /> Name: ��,_,,\ �'A�'�YSer� <br /> State License# �C.1�0�1�3 Explration Date: �(3 <br /> Lead Certificatlon Number: (�j '�.- ��-a$3 �1 _ Expiration Date: y <br /> (!br work on homes that were construcfed prlor b l978� (Cell) <br /> Phone: �D��y o�(��y L��` �,�qh {oifice) <br /> Mailing Address. -" '� �• •, iJ�j�Sk ��tY�r`�C�cv�11� Zlp: �S i <br /> Contact Person� App�iaartt is: ontra or / Homeowner �cirois o�) <br /> Emall and/or Fax� <br /> PROPERTY QWNE INFORMATfON: <br /> Name: � `� � <br /> Phone(daY)= f � � ����� Zlp: <br /> Addr�ss: ���' <br /> Email and/or Fax W <br /> PRQJECT INFORMAT[ON: <br /> Yype o!Project• My earth movement may roqaire <br /> � MCWD roviaw&permits: <br /> [� Door(s) ❑Remodel ❑Fire Damage Minnehaha Cr�ek Watershed Dlstrlct(MCWD) <br /> 0 Re-roof,asphalt ❑ Repair []Storm D&mage p9ephavlen,�MN�553�91 <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage phone: 952-A71-0590 <br /> ❑Re-roof,other{apecify) ❑SidEng []Other. (specffy) Fax: 852-471-0882 <br /> www_m inoehsha�reak.2r� <br /> ❑Window(s) �_� <br /> Overalf Pro ect Descriptic�n: G�Cg 1.�� S i� � <br /> Estimat�d Construction Valuation Project(excluding land) $ �, d C� � <br /> APPI.ICAN7 AGKN�WLEDG�MENT: <br /> . �grees ta provide all informatton required or tequested by the Building Department; <br /> . Certi�es that the information supplled is Uve and correct to the best of his/her krtowledge. The applicent recognizes that they <br /> are soleiy�esponsible for submitting a complete appllcation being aware that upon failur�to do so, the staff has no affemative <br /> but to re}ect it until it is comple#e; � <br /> . 5ome or ail of tt�e informatlon that yau ate asked to provide on this applicatiOn ls classil4ed by S�te lew as etther private or <br /> confcientiaf. P�lvate data is tnformation which generally cannot b� given to the public but cen be glven to fhe subject qf the <br /> data. Confidentia! data is informatlon which gener�ily cannot be glven to either the publlc ar the subject of the data- Our <br /> purpase and intended use of this inSormat�on is to annually update our records and records of other gov�mmental agencles <br /> re uired b law. If ou refuse to su he irrforrnation,the a lication me not be issued. <br /> Aoolicant's Sianature: <br /> � �� Dafie: �� 1 I I 1.� <br />