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<br />� Building Permit Application for Maintenance / Renovati
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<br />� (windows, doors siding, re-roof, etc.) ,�a Z �
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<br />� ; �_� Mailing Address: Permit number: 6� - Q(� g *
<br /> �0,� PO Box 66
<br />�< 0 � Q Crystal Bay, MN 55323-0066 Date received: �'� � � �
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<br /> I� ��'{� :: �., Street Address: Received by: r�J_ _
<br /> �.:' � ' �, �� 2750 Kelley Parkway Plan review fee: D I o� - DD 7�L
<br />� t9kEs�4'� Orono, MN 55356 � �
<br />�°` — Total Fee: �?2'S8 :+
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ;�
<br /> ,:g This application form must be completed in full and all required information must be submitted. �
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<br /> Incomplete applications will be returned. (P/ease print) �
<br />�,, GENERAL INFORMATION: -�
<br />�; Job Site Address: � S� G . � Q� ' - ��(Jc' �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Ho e? ❑ Yes No �
<br />�`�' If es, a s ecial event ermit is re uired with Police De artment and Cit Counci!a `�
<br /> �- Y P P q p y pproval 60 days prior to the event. Shuttle bus service will be �
<br /> � required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> �; C O N T R A C T OR/APPL CANT INFORMATION: h�
<br /> � Name: ��1+.� Si,cJ P� S"i7 ��-
<br />�' State License# Expiration Date: �
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<br /> : Lead Certification Number: Expiration Date:
<br /> � (for work on homes that were construcfed prior to 9978
<br /> Phone: Gf S Z � �3 __ �Z -7 / (office) (cell)
<br />�� Mailing Address: Z C j,� C�(�c-/La fivc City: � , : ����
<br />�' Contact Person: c� y, A lic nt is: Contractor / omeowner
<br />�` ' (N Z, pP ; (Circle One) '
<br />�: Email and/or Fax: �J c1�,, , S'w e t�► Sp y. � � M� i � � �,M �``—f �
<br /> � �
<br /> PROPERTY OWNER INFORMATION: �
<br /> Name: �Ct �liv�. S' �Z {.
<br /> Phone (day): �,� - �L 3 � � 2--7
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<br /> Address: -z �� L,,�.�,� �-,�„�.J (�,�� City: (iV��, � ZIP: �� �j�
<br /> aa: Email and/or Fax ,ti� S� -� �� , �a,,,�
<br /> PROJECT INFORMATION: �
<br /> �
<br /> Type of Project: Any earth movement may require ;�
<br /> MCWD review& ermits: ��
<br /> ❑ Door(s) �Remodel ❑ Fire Damage p
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd �
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 `�
<br /> �� Phone: 952-471-0590 �
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
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<br /> ` ❑Window(s) www.minnehahacreek.orq �
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<br />�`: Overall Project Description: '�� - �� c �� � �
<br />� Estimated Construction Valuation of Project (excluding land) $ ��S"`� U p� �
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<br /> t APPLICANT ACKNOWLEDGEMENT: ��
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<br />�- • Agrees to provide all information required or requested by the Building Department; �
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they
<br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative �
<br /> but to reject it until it is complete; ��
<br /> � �
<br />�' • Some or all of the information that you are asked to provide on this application is classified by State law as either private or �
<br />{ confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �
<br />�`:v data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our
<br /> j ' purpose and intended use of this information is to annually update our records and records of other govemmental agencies �
<br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. �
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<br />�= ApplicanYs Signature: Date: d �� � �' Z ���Z
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<br />�.�� Last Updated: 08-09-2011
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