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T <br /> � � � ,�� <br /> i �-� <br /> City of 4rono . <br /> Building Per it Application for Maintenanc� / Renovation <br /> windows, doors, slding, re-roof, etc.) <br /> Me1Nng Address; � <br /> '�D.�J� PO Box 66 Permlt number: / —!�� <br /> (a (� Crystal Bay,MN 66323-0066 pate reoeived; //- —/5 <br /> '� SYreet Address: Recetved by: �{�yj <br /> �t� �,� 2y60 Kelley Parkway Plan revlew fee• <br /> �rc� og Orono,MN 66368 • ' <br /> Main: 852-249-4600 Fex: 952-249-4918 w��nli.ci.nrono mn us Total Fee: <br /> Thls appllcatlon fo must be completed In full and ail requtred informatton must be su ed. ye�y� <br /> I campleto appiica�ians will be returned. (P/easa pNnt) � <br /> GENERA!INFqRMATION; <br /> Job 5ite qddress: 'Z, Z <br /> Wtlt this be a Parade of Names Remvdelers Showcase ome or ather Display Nome? Yes `�10 <br /> ffyes,e speclal event pe�rnit!s requ d tvlth Pallce popeNmant pnd Ctly Coundf epproval60 deya pdvrlo the event ShuNia bus eaivlce wU!be <br /> riequlied unless epp�(ca demonst�etes s+Allclent on-sl(e pa/tcing/s ave1/a61e, Non-pe�n!!!ed evenls wi7/nof 6a ailowed, <br /> CONTRAGTOF2/APPLICANT 1 FOi2MATIQM: <br /> Name: �yt D , .`7-�y"I� GOn? 7YLt7G'T,2'Oan� <br /> State Ltcense�f �, ) �, ( ExplraUon Date: <br /> Lead Certiflcatton Number. ��}.. Explrat(on Date: <br /> (for work on homes lhdf were n truat�o 9878 <br /> Pnone: ...-'3� (office) 52- 1 -Z (cell) <br /> Meiling Address; 2- v')z Zu o Cny: � � �ZIP: <br /> Contact Persan: Appllcant Is: o ac ot / Homeowner �a�ieone� <br /> Email and/or Fax; ,,.��- � � i,t,,� � <br /> PROPERTY OWNER INFORM IONs <br /> Name: �YJ�t��Ya�r�rN� '[?�1v I� <br /> Phone(day): �5 ����, <br /> Addrass: 5bb0 ' T Ciiy: '�',Lo� ZUZIP: <br /> �mall and/or Fax <br /> PROJECT INFORMATION: <br /> 7ype of Project: Any earth movatt►ent may require <br /> ❑Ooar(s) ❑Re odel [,�]Ff(e DBmaga MCWD revieW 8�permits: <br /> Minnehaha Creak Watershed Dlstrict(MCWD) <br /> ❑Re-root,esphalt ❑R c�lr ❑5torm bamage 18202 Ml�natonka 91vd <br /> ❑F2e-roof,ceder �]f2 lorallon ❑Water Oamage <br /> Deephaven,MN 55381 <br /> Phone: 952-471-0690 <br /> ❑Re-roof,otheT(specify) ❑Sf Ing ❑OtheC(sPeC)fy) Fax: 852-471-0682 <br /> Q W dow(s) <br /> }vww.minnehahacreek.Q qr <br /> Ovarall Projeot Descri tion: ��,U <br /> �stimated Canstruction Valu �on of ProJect exaludtng Iand) $ � ` `'-.— <br /> APPLICANT ACKNOWLED EMENT: <br /> � Agrees to provide all Info Uon requirad or requested by the Bulidtng papartment; <br /> . C.e�ifies that ihe tnformati supplfed f5 tf(18 afid Correct to the best of his/her knowledge. The appficant recogn[zes ihat ihey <br /> are solely responslble foi' bm(tllrlg a Coil7plete eppllC�tlon b01n�aware that upon fallure to do so,tfie atetf hae no alternaQvs <br /> but to reJeot it unUl It is co lete; <br /> • 5ome or ail of tho In(orm ton ihet you erp esked lo provide on lhis applical(on is dassified by State lew as ellher private br <br /> cohRdenllal. Private data s tntormadon whtch generally cannoi b�gfven to the public but can be given to tha subf ect of the <br /> ' data. Confldenitai data I Informatton whtch generaliy aannot be given to elther ihe pubifa or the subJect of ihe data. Our <br /> purposa end Intended us of lhis informalion Is to annually update our records and records oi other govemmental agencles <br /> ra uired b law. !f ou ref e to I the fa aU ,ihe a NcaUon ma not be(ssued. <br /> i <br /> AppiteanYs Signature: Date: �f�� "Z,2t�ib <br /> Ldst Updsled: OB-�9-2011 � <br /> � <br />