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�T�V/�1�20?6/TUE 09; 29 AM Elder Jones Buildind FAX �0, 952 854 4909 P. G02/002 <br /> � �, <br />, <br /> . <br /> City of 4rono <br /> Building Permit Application for kVlaintenance / Rep[acement/ Remodel --�tes�dentlal,:QNLY� <br /> (i.s. windows, doors, siding, re-roof, etc. --NO STRUCTURAL. �XPANS[ON) <br /> �O. `O Mailing Address: Permit number: ��/ � �� � <br /> ��r p0 8oxfi8 <br /> Crystal Bay,MN 55323-0066 aate received: U�. � ' <br /> � Strset Address: Recelved by: <br /> � ti�' 275o Kelley Parkway P1an review fee:. <br /> ��Akssxo��G Orano,MN 55356 �f <br /> Total Fse: d� <br /> Maln: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us /�� � �� <br /> This application form must be completed in ful! and all required information must be submitted_ <br /> Incomplete appficatlons will be raturned. (P/ease print) <br /> GENERAL INFORMATION��`� � ���� � q � <br /> Job Site Address: ��� <br /> Will this be a Parade of Homes,Remodeler howcase Home or other D9spfay Home7 ❑Yes o <br /> 1f yes,a special event permit is raquired with Police PeAartmenf and Gify Councll approva!60 dsys prfor fo the event. Shultle bus serv;ce wilf be <br /> required ur'------"---`'-----'--`�,- ���'�-`��-`����`����+s avaJlable. Non-permllted�vents wll!nof be alfowed. <br /> CONTRACTOR I API ��D At- Hoine Service, Inc, <br /> Name� 2690 Cuaxaberla�ad Pkwy, Ste 300 <br /> State License# Atlatlta, GA 30339-3913 Expiration Date: <br /> Lead Certification Nur Lic#CR268257 Ph. 763/542-$826 —�"�`��Explratfon Qate: �—J�� <br /> (for work an homes..._..._.............�.,.u��---- -- ---- <br /> Phone: (cell) (office) <br /> Mailing Address� Cit : Z1P� <br /> Contact person� � �3� —(60 Applicant i . Gontrac ' Homeowner (Clrcle One) <br /> Email and/or Fax: V ,e p� , <br /> PROP�RTY OWN�R INFQRMATIO : <br /> Name: � <br /> Phone(day): <br /> Address: City; Z1P: ' <br /> Email andlor Fax� <br /> PR�JECT f NFORMATION: Overafl pro'ect description: <br /> Typa of Pro)ect: Any earth movement may also require <br /> �Door(s) ❑Remodel ❑ Fire bamage <br /> MCWD rsview&permlts: <br /> Minnehaha Creek Watershed Dlstrict(MCWD) <br /> ❑Re-roof,asphalt ❑Repair []Storm Damage 15320 Minnetonka Blvd <br /> ❑Ra-roof,cedar ❑Restoration ❑Water Damage Minnetonka,MN 55345 <br /> ❑Re-rpof,other(sPecify) �Siding 0 Other:(speclfy) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> �-Window(s �,r��_ www.minnehahacreek.arq <br /> Estimated Construction VaEuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all informat[fln requirad or raquested by the Building Department; <br /> . Certifies that the information supplied is#rue and correct to the best of his/her knowledge. The applicant reoognizes thet they are <br /> solely�esponslble fnr submitfing a complete application being aware that upon failure to do so,the s#aff has no alternative but to <br /> reject if until it is complete; <br /> • Some or afI of the information that you ara asked to provide on thls appllcation �s classifled by State 1aw as either private or <br /> eonfldentlel. Private data is information which generaEly cannot be given to the public but can be given to th�subject of the data. <br /> Confid�ntial data is information which generally cannot be glven t�elther the public or the subJect af the data. �ur purpose and <br /> Intended use of thls Inf rmatlon is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I e inform ,th a lication ma not be Issued. <br /> Applicant's Signatur Date: 1D`��"��;E� <br /> Owner's 5ignatur : Date: <br /> �ast URdated:Ja�uary 20�6 <br />