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� - Gity af Ora�a <br /> ' Buiiding Permit Application for Maintenance / �enovation <br /> (windows, doors, siding, rewrot�#, �tc.) <br /> Maflf»g Address: Permit number. r� i I � �Q <br /> 0.�,�,�Q PO�ox 66 <br /> �. <br /> Crystal Bay, MN 5532',rQ066 D2te rgC�ived_ �' <br /> �, StreetAddr�ss: Received by: � <br /> ''� � 2750 Kailey Parkway Ptan review fiea: 'J' <br /> �q�.��o� Orono, MN 55356 /� <br /> 7'otai F�e� �lUv- �-'�: <br /> Meln: 952-249�640 Fax: g52-249-461B www.cs.arono.mn.us <br /> 3'his application form must be completed in fE.Ell and all required Infom'iation trtust be submi�ted. <br /> Incomptete appNcatlqns will be returned. (Please p»nt) <br /> .fob S te Add e05 MATION: � ��„�- ��� ,� �^ w....,._._.. `��1���� <br /> � (�V� <br /> Will this ba a Parade of�iomes,Remodelers$howcase Home or t�ther Display liottte? Q Yes No <br /> !f yes,a special evetrt permlt!s ropulrgd wlth Pollce Department and City Gbuncil approval 60 days prfor ttl tite eV9»t- Shut!!a 6us S9rvlC9 wlJ7 b� <br /> requlred unless applicant demorrstretes sufh'aant ans�Ye paliCing is�vdlfablg. Non-permltied events wil!nof be allowed. <br /> CON'CRACTQR/APPLICANT lNFORMATiON: <br /> Name: 1�r��+�a\ �'Av�-t�Ser� <br /> State License# ��,1�jp9�'� Expiration Da#e: ���f 3t <br /> Lead Certification Number: �j�"('� a'�-a$3 —1 Expiration Date: _ ___�J�� <br /> (far work on homea tltat wer�e consfrucfed prLor to 9878 <br /> Phone: �S I�o�Z{��{-O S�' �(4 Ar. (Qffice} (ce11) — <br /> Mailing Address: •• ,. Wey� CjtY��pS�cv�11� ZIP: s — <br /> Contact P�rson_ Appficant is: ontra / Momeowner (Clreirt One) <br /> Emai(and/or F'ax� <br /> PROPERTY OWN�R 1�ORMATION;(. �..�nn� 1 I <br /> Name; �1 dl.rU ,�` ,� • — <br /> Phone(day): �� or2 • aa'1 I '31�� <br /> Address: City: ZIP: <br /> Emai€and/or Fax <br /> PROJECT tNFORMATION: <br /> 'Type of Project; Any earth movement m�y r�quire <br /> ❑ Door(s) ❑ Remodel ❑Flre Damage MCWD revlew�permlts: <br /> Minnehaha Craek Watershed�istrict(MCWI7) ( <br /> ❑ R�roof,asphalt [] Ftepair �Storm Damage 18202 Minnetonka Blvd <br /> � Re-roof,cedar ❑ Restoration ❑Water Damage ' DeSphaven,MN 55391 � <br /> Phor►e: 852�71-0590 <br /> ❑ Re-roof,o#her(sp�cify) � Siding �Qther, (specify} F2x: 952-�79-Q682 <br /> Window(g) www.minnehahecreek.orq <br /> Qvera[I Project Description: C,p C�.ri 1.C3 ' <br /> Estirnated Constructlon Valuati n of Pro3ect excludin land $ .� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provPde all info�rnation required or requested by the BulldFng Department; <br /> . Certt�es that the ln�ormatton supplied is true and correct to the best af his/her knawledge. The epplicant recognizes that they <br /> are soleiy responslble tar subm9�ing a camp��ta applicat�on being aware that upan falture to do so, the sta#�has r,o altemative <br /> but to reject i�until it is complete; <br /> • Seme or all of the informs#ion #hat you are asked to provide on this applicatian is cl�ssified by State iaw as e�ther p�ivate pr <br /> canfldentlaE_ Private data is inf�rmalion whi�h ge�eratly cannot 6e given to the public 8Ut can be given to the subfect of the ' <br /> data. Confldentlaf data is 'snformation wh'sch generally cannot be given to e�ther !he pub!)C or the subject of the data. Our � <br /> purpose and intended use of this information is to annually updat� our records and records of ather govemm�nta! �genefes <br /> re ulred b faw_ If reiusg t�Su ! th�inform�tion iha a lication ma not be issued. <br /> Aoflficant's Sianature: Date: ������� <br />