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<br /> . C ity of O ro n o �Z� �
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<br /> . Building Permit Applicafivn for IVlaintenance / Renovation r�
<br /> (windows, doors, siding, re-roof, etc.) �
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<br /> Mailing Address: Permit number:
<br /> �,i,�,j� PO Box 66 ;
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<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> � � s, � Streef Address: Received by: �
<br /> � �I GY %
<br /> ��n "�'� �ti 2750 Kelley Parkway Plan review fee: ��
<br /> '� Orono, MN 55356 �
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<br /> Total Fee: ,�:�
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �
<br /> This appfication form must be completed in full and all required information must be submitted. ,;
<br /> Incomplete applications will be returned. (Please prinf)
<br /> GENERAL INFORMATION: �
<br /> Job Site Address: ���`j ��,,y�,q ��,�,,a,4 �'/Z v . `�w �;
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or oth r Display Home? ❑ Yes ,s[�No �
<br /> If yes,a special event permit rs required with Pofice Department and City Council approval 60 days prior to the evenf. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed. V�
<br /> CONTRACTOR/APPLICANT INFORMATION: :`�
<br /> Name: `��� �;�i.������ Tr� y
<br /> State License# / ��r-�f�7��� Expiration Date: ��-3�-/1 ..�
<br /> Lead Certification Number Expiration Date: � �
<br /> (for work on homes fhat were constructed prior fo 1978
<br /> p Phone: _ �, � (office) (cell) >�
<br />' Maifin Address: ' •- �j r-._ �
<br /> g —L���— s�' /�G�c City: � fi l�j� ZIP: .5 53�C'' �
<br /> Contact Person: �� , l�r��� ,��=�s-lr Applicant is: Contractor / Homeowner (Circle One) �
<br /> Email and/or Fax: �fi
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<br /> PROPERTY OWNE�INFORMATION: �
<br /> Name: c�'n £� �_:A,�i,,�. �%���
<br /> Phone (day): C�7.��-,�!�//- .��O�,L�—
<br /> Address: J�/tj j�� �j�,.�� City:��,,�� ZIP: "
<br /> Email and/or Fax
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<br /> ��rv�:
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<br /> PROJECT INFORMATION: �;�
<br /> Type of Project: Any earth movement may require ���
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits: =ks
<br /> ❑ Fire Damage a
<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 /> ,�,
<br /> Phone: 952-471-0590 �
<br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 '`�
<br /> ❑Window(s)
<br /> www.minnehahacreek.orq `�
<br /> ._'�
<br /> Overall Project Description:�`�;G � 7�.,,r,� ��.�,r ��
<br /> Estimated Construction Valuation of Proje— ct(cluding land) $ p� -� ��
<br /> �l3 „�:
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<br /> APPLICANT ACKNOWLEDGEMENT: ,�
<br /> • Agrees to provide all information required or requested by the Building Department;
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<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 applicafion being aware that upon failure to do so, the staff has no alternative `'j
<br /> but to reject it until it is complete; '��
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<br /> • Some or all of the informafion that you are asked to provide on this application is classified by State law as either private or ��`�
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<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the �°�
<br /> data. Confidential data is information which enerall cannot be �
<br /> g y given to either the public or the subject of the data. Our �
<br /> purpose and intended use of this information is to annually update our records and records of other governmental 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 /> AppficanYs Signature: �—` � Date: �����1'j �
<br /> Last Updated: 08-09-2011
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