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• II <br /> ' ♦ , . �L , i y I��� . <br /> � ���,�3 <br /> � 3" � / �5. �� <br /> �ity �►f Orona <br /> �uiiding Permit Application for Maintenance / Renovatio <br /> windaws, doors, siding, re-�oof, etc. <br /> Maiiing Addre33: Permit number. o2D/ d�� � <br /> O��.�0 PO Box 66 <br /> Crystal Bay,MN 55323-oo6s Date rec�ived: �3' l3 <br /> �� SGeat Add�ass: Received by: � <br /> �'4'G� �Orono,MN 55356 Y Pian rev�w fee: <br /> �� Total Fes_ <br /> Main: 952-2d9-4600 Fax: 952-249-46t6 vaarvv.ci.arona.mn.us <br /> ,This apptication form must be completed in fuit and ail required information must be submitted. <br /> In�ampiete applications will be retumed. (Ptease print) <br /> GENERAL INFORMATiON: <br /> Job Slte Addreaa: '2G'�(Z_K���� DikQ� / <br /> ' Will this be a Parade of Ifomes,Remod�ers Showcase Home a�other Display Hame? Yes No <br /> tf yas,a s�7�event�r�t ia requNed with Pdiae Departmant end Clly Coundf approvsl 80 daya prlor fo the eveM. ShtAtle bus� ce wU!be <br /> �ired unfess appl/cant demonstrates su/flcAent on-slte parking is avelJable. /Von-permiKed euents w!/I not 6e a�lowed. I <br /> COIdTRAGTQR/APPLICANT INFORMATION: <br /> Name: t�J ?l4Vwt� �j n1$T YwG�/ <br /> State License'# G S LZ,1 Q b! Expira�on Date: <br /> Lead Certiftcakion Number: � ��.. E�cpiration Date: <br /> (fu�work ap homes that were co�pNor to 1978 <br /> Phone: �� (office) '�,. � . (cell) <br /> Mailing Addre�s: Z.-Su,j�, Zu o CitY: IP: <br /> Gontact Persdn: ApplicaM is: a Homeowner cn�s aK� <br /> Emaif and(or t�ax: �� t � <br /> PROPERTY CIWNER iNFORMATION: <br /> Name: i t�J = �4'f t� a LM <br /> Phone(dsY)� , RSZ-4!5^ �'�- <br /> Address: Jd0 3 CrtY� "�•L��S p�,at ZiP: <br /> Email andior F'ax GA � <br /> PROJECT INFQRMATtON: <br /> Type of Projec�: Any eartfi mavement may ire <br /> ❑Door(s) ❑Remod� ❑Fire Damage MCWLI revfew 8 permits: <br /> Minnehaha Cr�k Watershed Dis ' (MCWD) <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 182Q2 hfinnetaika BNci <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-47'i-0590 <br /> ❑Re-roof,otheir(spectiy) ❑Siding ❑Other.(specity} Fax: 952-471-0682 <br /> �Window(s) www.minnehahaaeek_ara <br /> Overall Pro}edt flescription: F',�.;3K (r1/l��? </� <br /> Estimat�d Comstruction Ystuation of Project(excluding land) S �iZ, (�O(J, --- <br /> � <br /> AFPLICANT ACKNOWLEDGEMENT: <br /> • Agrees provide ali infortnation re�ired�request�d by the$uihiin9 dePardne�t: <br /> • C�rUfisslthat the infortnaiion suppiied is true and carrect to the best oF li�slher knowledge. The applicant reoogn" es Utat they <br /> are sale,y responsibie for submitting a c�mplete appC�afion being aware that upan.fetlute to dQ so,the sfaff has o altemative <br /> bui to reject tt until it is comptete; <br /> • Some or all of the infoRnation that you are asked to prouide on fhis appiicetkin is classified by State law as si r private or <br /> cor�fidential. Private data is infamadon which gen�aNy carsnot be giverr to the public but ca�be given to the bjed of the <br /> data. Ci nfldentla! data is ir�formatfon which generalty cannot be given W ei�er the puWic or the subject af data. Our <br /> purposa and intended use of this intormatiort is W snnualiy update our reeords and records of a�hher govemme agendes <br /> uired law. if u rcfuse i atio the a ic�tion ma not be issued. <br /> Appiicant's Sign�ture: Date: ��y' � <br /> Last llpdated: 08-09-2011 <br />