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, C��y o� ��°o�� <br /> � ��elclo�c� �ermit Applicatior� for 111�a6nten�nce / Replacement / Rernodel — Residenti�l Ot�LY <br /> `io�, �6r�c�ow�9 �o���, ������> ������o�s ���, � �� ��l�l���'tJFt�l� EXP�C���f�E�Z <br /> ��� Mailing Address: Permit number: a�'d(� -(�L S <br /> � PO Box 66 <br /> Crystal Bay, MN 55323-0066 ' � Date received: 5"�� '�� <br /> "Y <br /> Street Address: ��� � eceived by: �.� <br /> ti�, � G� 2750 Kelley Parkway 5 -� `�� Plan review fee: ' (� �t ��,� <br /> Orono, MN 55356 <br /> lqkES H��� <br /> Total Fee: �� S� <br /> Main: 952-249-4600 Fax: 952-249-4616 wv,����-.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFOl21VIATION: <br /> Job Site/4ddress: 2 � p ��v�-� <br /> Will this be a Parade of Homes, Remod�lers Showcase Home or other Display Home? Yes ,B F!o <br /> lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates suKicient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOl2/APP CANT INFORMATION: <br /> Name: ..e <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfructed prior to 1978 <br /> Phone: (cell) t� ( — � (office) <br /> Mailing Address: p � c�j ��� City: � ZIP: S3 <br /> Contact Person: � � Applicant is: Contractor / omeo 2 (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER NFORM�10 • y <br /> Name: ��lGt� `P-fi'�(�t,�i� SLc{vl►'�"� <br /> Phone (day): ��—�LJ�—g��j� <br /> Address: ��'7� CQ SCO P��rn.'� �Px� � City: Qr�v� � ZIP: �3�( I <br /> Email and/or Fax: r�.;k�-�2.�r �a q,w�c�►� r C�v�-� <br /> v <br /> PROJECT INFORIIAATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> ,� Door(s)�'���f � Remodel �wQ�y MCWD review&permits: <br /> ❑ Fire Damage <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Minnetonka, MN 55345 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify} Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding lanci} $ <br /> APPLICANTACKNOWLEDGEMENT: �-�� �� �J�,��S--.�s� ��r� � �� <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 are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <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 data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the information, the a lication ma not be issued. <br /> Applicant's Signature: Date: � <br /> Owner's Signature: Date: <br /> Last Updated:January 2016 <br />