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�. <br /> . X�, <br /> . Cr� af arona ��, <br /> . Bu�lding Permit Application for Mainten nce`I ��nova#ian <br /> � (windows, door�, sidin , re-ro ,,, etc.) <br /> MaUing Address: '�"� ' �' ,. i�G <br /> ��,� PO Sox 66 ��,; Perrnit number: �- �� � � � ` <br /> Q Q Crys#al Bay,MN 5�323-OOSB �k+i Date received: �� � <br /> �� �, Sfreet Address: ��4 Recelved by. , ' <br /> �, G�' 2750 Keliey ParkwaY ';'E: Plan revfevrr fee_ <br /> -��s�dg� Orona, MN 55356 �i''� �.: > <br /> ,°,,. To#al�ee: '�;_ ` l� '"i�i <br /> Main: 952-249-4500 Fax= 952-249�B1$ www.Ci.orono.mn.us ,� - <br /> This appGcation form rr;ust be compl�ted in ful[and alf requireci in 'tmation must be submitted. � • ?� � <br /> Incomplete applications wi[i be retu�ed. (P;��ase print) � 1 j�% i , <br /> G�N�RAL IN�ORMA1'ION: r � , _ 1 ,, F',' <br /> Job Site Address: ----- � (�v�Cj ��+(Y��c ��ri �-�.�� <br /> Will this be� P�r�de af Homes, Remodelers Showcase Home or other pis ay Home? Yes No <br /> !i yrs,a specia/event permit is required wfth Pol)ce Departmant and Clty Cauncll a�proval BO d�ys pdor fo the evenf. Shutfle 6us senrice wil/be <br /> requfrsad unless appllCant d�monatrxfea acJfPfcient on�ife perlcin�is eVsilable. Non;�e,n,►rrBa�v�m$W;a no�be anowed. <br /> ���,� <br /> CONTRACTOR/APPLICANT lNfORMA71dN: :� <br /> Name: 1��@'r���o.\ � 'A`nc�tCSeiN '��i. <br /> --- <br /> State License# �,��-�oq g� ;�xpiration Date: �j�� <br /> ;.. __. __....._ <br /> Lead Certifrcation Num6er� �"�� �'�.a$� �� �xpiration Date: �j f�,r <br /> (fnr wnrlr on homgs#/aat were canstruci�ed prlor to 9978 :' ' <br /> Phone: (o��-' �(¢C{..t1,0�qn (office) :i;; (cell) <br /> Mailing Addre&s: l�a� CO.��, �•G•� W�S�}' C���Sevt11� ZIP: SSl�� <br /> Contact�'erson: Applicant is: � bntra / Homeowner (CfrcSe One) <br /> �ma9i and/or Fax: ,.��, ! <br /> �,�•; <br /> pROP�R'rY ownfER 1NFORMATION: ��! <br /> Name: ��ob��'�' —'--- - :€' <br /> , ��r..- <br /> Pftone(day): " <br /> ,f, <br /> Address: � Ci�iar: ZIP: <br /> �mail and/ar Fax ': � <br /> ,�.I. <br /> „ <br /> PRQJECT !N�'ORMATION: <br /> Type of Project: My earth mQvemant may require <br /> '�: <br /> � MCWD re�ew&permits: <br /> ❑Door(s) 0 Remodel ❑Fire Damage ''''�,�haha Creek Vllate�shed qistrict(MCWD) <br /> 0 Re-rQof,asphalt �] Repair ❑ Storrn Damage �" 18202 Minnetonka Blvd <br /> �Re-rodf,�edar [� Restoration �Water Damsge F;, �eeph�ven, MN 55391 <br /> .� Phane: 952-471-D59� <br /> ❑Re-�oo�, other(specify) �s�d�n� 0 Other:(specify) •;;;', F�x: 952-471-o6sz <br /> �a� � �(� ;,"� www.minnehshacreek.arq <br /> '�Window(s) u%� :�;,. <br /> �;�, <br /> Overall Projec# Description: � o'�? �,�}{ G{p�c� l�', `QJX�S � � <br /> Estimated Ccnstruct9on Valuation of Pro ect exctudln land $ �; � <br /> F,: <br /> — <br /> APPLICANT ACKNOWLEDGEMENT: �'I <br /> �;. <br /> . Agrees to provlde all Inform�tlon required or requested by th�Building Dep�rtrrt�nt; <br /> . Certffles that the Informatfon supplied is true ancl correct to the best of h9s/herv�nowledge. The applicant �ecognizes that#hey <br /> are solely resppnslble for submitting a Compfete 2ppf9C�tiort being aware that�r�on faiiure to do sa, the staff has no alfemativ� <br /> buf#o r�ject it untii�t is complets; <br /> ���; <br /> • Some or a!I o��he in#orma#ion that you are asked to provide on thfs appllcati''� fs ciasslfled by Steie law as elther prfvate or <br /> confident9al, Privgte data is ini�rmation vvhich generaliy cannot be glven tv t. pubfic but can be given to the subject of the <br /> dafa. Confidentia! dats is infiormaUon which ganerally cannot be given ta e' er the public or the subject of tfie data. bur <br /> purpase �nd intended us� of#his information is to annually update our recoc�$ and records of ather govemmental egencies <br /> re uired b iaw, If ou rofuse to su I the information,the a fication ma na�'�e issued. <br /> AAnfican#'s 5ianature: ��� ;;.''. D2te: �U���� �� <br /> ::il�� <br /> <„ <br /> %'.i�'; <br />