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� <br /> s <br /> Gity of �rono <br /> 13uilding Permit Application �ar Maintenance / Renovation <br /> (windaws, doors, siding, re-roof, �tc.) <br /> Mailing Addross: Permit number. <br /> '�►�� PO Box 66 <br /> Q � Crystat eay.MN 55323-0p68 Date received: <br /> o+ Str'eetAdd►ess: ReCeived by: <br /> �� . ��' 2750 Kelley Parkway Plan review fee: <br /> ���p4� Orona. MN SS356 <br /> Total Fee: <br /> Maln_ 952-249�Bp0 Fax= 952-249-d616 www.ci.orQno.mn.us <br /> T1'�is application form must be c�mpleted in tuil�nd all Tequired information must be submitte4. <br /> Incomplete appllcaitions wfll be retumed. (Please print) <br /> GENERAL INFORMATION: . � � �„ �� • <br /> Job Site Address; <br /> Wil!this be a Parade of Homas, Remodeters Shaw se Home or other DEspl�y Home7 Yes No <br /> !f yes,a spBc;al even[permlt 1a requirnd with Falice Dgpartm�nt and City Courtcll approva!60 days privr to the etrent Shuft/e bus sen�ice wid be <br /> �equired unless applicant demonstrates au/Frcien't onslte parking�!s ava,7able. Non-pem,iKed e vents w;11 not be allo►e�d <br /> CONTRACTOR 1 APPLICANT INFORMATION: <br /> Name: �t,n 1 ,A�t�(�e� <br /> State License# �C,��p�g Expir�fion date_ 3 I 31 <br /> t�ead Certficatlon Number: (� ^�'� � ��� � �xpiration Date: t( <br /> (for work on homes tha!wenB construci�ed pr/or to i978 <br /> Phone: (,a��-^ v'� .�t{,O�" h (ofFce) (cell) <br /> Mailing Address: Icj o� , � ��G�, W�SS�- Ci�Y= v►1 �. ZIP: SS 1� <br /> Contact Person� Applicant is: on / Homeowner �c��o�� <br /> Email and/or Fax: <br /> PROI��RTY OWNER f�RMATION: � <br /> Name: <br /> Phane(day): <br /> A�ddress: � CitY� Zf P: <br /> �mail and/or Fax <br /> PROJEC7INFORMATION: <br /> Type of Project� <br /> Any eartlt movement may reqnire <br /> ���s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> [�Re-roof,asphatt Minnehaha Creek Watershed Dlstrict(MCWD) <br /> ❑Repalr ❑S#orm Damage 18202 Minnetonka Bivd <br /> 0 Re-roof,cedar ❑ Restoration ❑Wa#er Damage ��p��n, MN 55391 <br /> ❑Re-roof,ott�er(speciry) ❑Sidfng ❑Other: � q Phone: 952-q�71-0590 <br /> � Pe fY) Fax� 952-479�p682 <br /> �Window(s) www.minnehahacr�ek.or <br /> OverallProjectbescription:- PI „a,c-� 1 w� Ow�� �� . ' -� 'Q <br /> �stimated Canstructton Valuatlon of ProJe�t(excluding land $ �� ��� -� <br /> APPLICAN7 A,CKNOWLEDG�MENT: ��'�� <br /> • Agrees to provlde afl inform2�Gon required or reque�ted by the 8uilding Departmonf; <br /> • Certifies that the ir�formation supplioci is true�nd txitrect to the best of his/her knowiedge, The applicanE recogniaes that they <br /> are solely responsible for submi#ting a complete application being aware that upon failure to do so,the staff has no altemative <br /> but to reject it until it is compEete; <br /> • Sorne o�all of the ir�formation that you are asked to provide on this applicatfon is classiAed by State law as either private er <br /> cartfidenbal, Private data is information which gaherally cannot be g�ren �o the public but can be given to the subject of the <br /> data. Cvnfidentfal data Is infvrmatfon which gen�rally cannat be given to eiEher thv public or the subject of the data. Our <br /> purpose and intended use af this information is to annually updaie our records and records of other govemmeMal a8encies <br /> r uired b law. If u refuSe to su I the infarmatifln,the� lication ma not be issued. <br /> At�oiicant's Sianature: Q �� Date: r <br /> �7���� <br />