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� . ,._� NEW EXTERIORS, INC Fax:763-315-8908 Sep 26 2011 U1:32pm P002/OOd <br /> City of Qrono <br /> Building Permit Application fior Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. �� -� <br /> Og,�,�0 PO BOX 66 <br /> Crystal Bay,MN 55323-0066 Date reoefved: � / <br /> A �.I� Slreet Add�9ss: Re�e�ed by: <br /> � o�' 2750 Kelley Pa�lcway Plan review 6ee: <br /> � Orono, MN 55356 <br /> Main: 952-24�-�600 Fax: 952-249-4616 www.ci.orono.mr,us Total Fee: a�/�,� �_ <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications wi11 be returned. (P/ease prrnE) <br /> GENERAL INFORMATION: <br /> Job Sit�Address: ��' ' {� ��i <br /> WIII this be a Parade of Homes, Remodelers Shvwcase Home cr othe�Display Hcme? ❑Yes No <br /> ff y�s,a specla/eve,rt pem�it is�quNed whh Potia�e Depa�trr�ern antl G7y Council approval�days prior b the evenc SAume nus servi�e w�/�pe <br /> requlred unJess applicaM demonstratea�u�Tioient on-slTe pa�king ia available. Noo-perm,�ted ewer�s wlll not be al�Owed. <br /> CONTRACTOR/APPUC T INFORM TION: <br /> Name: ) �G � �. <br /> Stffie Lioense# � S,S � Expiration Date: `3 � � <br /> Lead Certification Number. { T„ _ � E�cpiration Date: fm -a D yS <br /> (fbr work on homes that wer�e cansbvcted prfor to 1978 <br /> Phone: `�(0,3 .3 l5'- �j �C� ���) (cell) <br /> Mailing Address: � •( � City: f �y� ZIP: � s'�' � <br /> Contact Perscn: � �L ' Applicant is: ontractar / Homeowner �cz��o„e� <br /> Email and/or Fax: [ f�.,�..� <br /> PROPERTY OWNER NFORMA`T�ON:� <br /> Name: j /`1��'f,y� <br /> Phone(day): �I� ����_t�� <br /> Address: �,yy� � City: ZIP: <br /> Email a�nd/or Fax <br /> PROJECT INFORMATION: <br /> Type of ProJect: Any earth movement may require <br /> �Door(S) ❑Remodel ❑Fire Damage MC�����perm�s= <br /> Minnehaha Creek Watershed District(MCWD) <br /> Re-roof,asphelt ❑Repair ❑Storm Damage 18202 Minnzbonka Blvd • <br /> ❑Re-roof,cedar ❑Restor'ation ❑Water Damage �e9phaven, MN 55391 <br /> ❑Re-roof,other(spocity) ❑Sidin Phone: 95z�71-0590 <br /> 9 ❑Other;(specify) Fax: 952-471-0682 <br /> ❑Window(s) .minne aha ek.o <br /> Overall Pro'ect Descri 'o�: _ � , �.� � <br /> Estimated Construction Valuation of Project(sxcluding land $ / <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all informaUon required o�requested by the Building Department; <br /> • Certifies that the information supplied is true and cprrect to the best oF his/her knWvledge. The applicant f'eCognizes that they <br /> ere soley responsible fvr submitting� complste application being aware that upon failure to do so, the staff has no altemative <br /> but to reject it until it is comple0e; <br /> • Some or all of the information fhat you are asked to provide on this application is dassified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to tha public but can be given to the subject of the <br /> data. Confidential data is inform bon which gene lly cannot be given to either the public or the subject oF the data. Ovr <br /> purpose and intended use of th' in � n is annually update our records and reootds of other governmental agenCies <br /> uired b law. (f ou refuse u e i ation the a lication ma not be issued. <br /> � <br /> Applicar�t's Signature: � D��: �� /� <br /> r <br /> Last Updated: 08-09-2011 <br />