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Au�.28.2011 02 _29 PM Dakota Czaftsma� 6127600628 ��G�. 11 1 <br /> � � � �l� G� <br /> . r� ���� � <br /> City of Orono/�� <br /> �� �� <br /> Bui�ding Permit Application for Maintenance / Renovation <br /> windows tloors, sldirrg, re-�rovf, etc.) <br /> O�O=�O Mai/iPOBox Bs Permltnumber: - � <br /> Crystal Bey, MN 55823-OOBB DAie netoived: <br /> � ` 5h�eet Add►ess: Rocenred by: <br /> � 2750 Kelley Parkway Plan reviewfee: <br /> � Crono,MN 55356 <br /> ���' Toial P°��: <br /> Me�n; 952�a9-4600 Fex: 952-248-4676 �nnNw ci ero�, mn_us <br /> This appllcadon toRn muat be completed in full and all required informatlon must be submitte . <br /> Inc4mplete 8pp11caqons wlll be r�eturned. (Please print) /! <br /> CiLNERAL INPORMATION: 6 <br /> Job 91te Addresa: <br /> Will thla be a Parede of Homss, Remalelers�hvwcase Home or o e Display Nome� Yea . o <br /> N yee,a speda/avq�tf pormit!e i+vquined w�Yh P1olice Depellr►lent M�d C/fy Courroll approvo/60 dayo prior to fho eyonf, 3huKl9!wa Yn%I ba <br /> revup eo unress ao�pcanr demanstrat�a su�icienf on.sife perkny is availeb/a Non-pen�llted evants will not be sllowed. <br /> CONTRACTOR/AP NT IN� ,M ON: <br /> Name: <br /> State License# �xpiration DatQ: .- d,- ( <br /> Lo�d Certli{c�tion Number. � �- Expirativn Date: �B�� <br /> (fvr w��rk w,h cons� Ito 1878 <br /> Phone: — (?-� (offiee) (cell) <br /> Mailing Address: City: �T ZIP: <br /> Contad Pe�9on: Applicant fe: �� Nomsowner � ��000N <br /> Email and/or�ax: <br /> PROPERTY OWNER RMATI N: � <br /> Name: <br /> Phone(day): - (j.- � � <br /> Address: City: ZIP;. �3 <br /> �mail and/o►Fax <br /> R CT NFORMATION: <br /> Xpe Project: Any aa mowmsoc may raqulre <br /> ❑ Doo�(:) []Rsmoaol p Fire Damage <br /> MCWp review S pet�Cnits: <br /> Minnehaha Crsak V1Aatsrshed DiaMct�MCWD) <br /> e-roof.asphalt ❑f�apalr ❑Storm DBmape 18202 Minnetonka Blvd <br /> Ro-roof,cedar [� Re6toraUon 0 Wato�Damage DeephBven,MIV 55381 <br /> Phonc: 982-477�0590 <br /> ❑Re-root,other(apeo�iy) ❑Sidi�p ❑O�ea(specJfy) Fwc: 95Z-471-0682 <br /> ❑WindOw(e) <br /> Overall Pro ect�asc�i Iolr <br /> Esllmaked Co�structivn V�luqqon oTP�vject(exoluding lan� t (p,�p <br /> APPLICANT ACKNOWLEDGEMENT: <br /> . Ag�es to provide all Intortnation requiced or requested by the Bullding Deparlmenl; <br /> • CeKties ttlat itle intomfetlon supplied is trua�nd co�re�l t0 tne best oi h1s�►�er knowled0e. The applica�i racognizss ihat thay <br /> are solely reeponeible for submftiing a c�mpktv aDDlication being aw�re that up4n I�ilu�lV d0 so, the Stet�hes nd eltemetiVe <br /> but to reject i!until it is complete; <br /> • S,ome or all of!he infqmation that you are askod to provide on this application is dass'died by 6taie law ao ollhdr prhralc or <br /> coMldanUal. PAvate da18 I9 infom�stion which gen�rally c,annot be given to the public but ctm be given !o the supjsat of 1he <br /> dace. conRdenaal aata is inivrmation which generally cannot bs piven l0 BiUlef V1e publlC o� the sut�eCt M the data. t)ur <br /> purpose and intonded uao of thia informabon is !o annually updnte our racorda end recorcls of olher govemrr�rentp,l egenGas <br /> re ulred 1aw. iF u refuse I 1h�infonnat'on,the a lieation ma not be issued. <br /> ApPlicanYs SiAnature: oate: �•'Q�^��11 <br /> �.a�t uPdmed: os-oa-zo�� <br />