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, , Jun. 7. 2017 11 :41AM � � u No. 3665 P. 1
<br /> City af �rono
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<br /> Building Permit Application for Maintenance/ Replacement!Remudel—,. ;."'.;�d��i.t���:�;�lV;��
<br /> (i.e,windows, doars,siding� re-raof,etc.--NO STRUCTURAL EXPANSION)
<br /> yr� Mslling Address: --:.�:,:,:--=.:..R:.� �— �?i - ""'i�:=:
<br /> PO Box 66 ��Re�fil.l,4;^ntr�i4�r�:��Y �=�.: ..:._... .�_� �
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<br /> Grystal Bay,MN 55323-0086 �pa�;i�rved',�J�=���;;�!':°`'°x=�--.�;;���; _
<br /> Street Address: =�I�ecelVed;ti�:���- __ - - ---
<br /> � � 2750 Kalle Pa -' � - -
<br /> �'� ti y 'ic`uay ::P.f��T��C�$4!!14��=- -_ - -
<br /> �q �w Orono,MN 55356 - _ ' __ ___ --__ -- -
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<br /> Maln' 952�249-4600 Fax: 952-249-4696 www.a.orono.mn.us - -- - �:.,�-
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<br /> This appllc�t(on form must be completed in full and al(required information must be submitted.
<br /> Incomplete appltcatlons will be retumed. (Please print)
<br /> GENERAL INFORAAATION: � ���1 �
<br /> Job Site Address: �
<br /> Wlll thls foe a Parade of Homes, emodelers 8ho se Home or oEher Dlsplay HomeT Yes Ido
<br /> N yes,d 8pecial event permit is required wifh PoGce Deparfmenf and Cify Coundl approva!80 days pryor fp the evenK ShufHe bus serv w'�l be
<br /> requhed unless applicant demonstrafes sulficient on-site parkfng ls ava!lable. Nony,�ar�nitted evenfs wrTi not be allowed.
<br /> CON7RACTORlAP�CANTINFORMATIQ ; � �Q��
<br /> Name: ,Q,r' � �� � .
<br /> C'75tate License# '� ^ Expir�tion Date: �
<br /> �.ead Certlflcatlort Number: (,o Expiratbn Date:
<br /> (lPo1'work on hamea thet were cons cted o�ta 197'B
<br /> Phone: (cell) �j�' a � � 7 (of�ice)
<br /> Mailing Address: Cit � ZIP:
<br /> Contact Person: ,�� Appllcant Is: Co�tra / Homeowner �ci��o o�a
<br /> Emafl and/or Fax: ,� r � , ��fY�
<br /> PROPERTY OWNER INFOR ATION:
<br /> Name: (Jl� ,�
<br /> Phone(day): .-� � �
<br /> Address: � �City�dY'�c� ZIP�`}���
<br /> Emall ahdlor Fax:
<br /> PROJECT INFORMATION: Overall ro ect descr� 'Nan:
<br /> Type oF P�oject: Any earth movament may also requlroe
<br /> ❑Door(s) ❑Ramodel �Fire Damage MCWD review 8 permits: '
<br /> �Re-rooF,asphalt ❑Repair ❑Storm pamage Mlnnehaha Creek Watershed Districl(AACWb)
<br /> 15320 Minnetonka Blvd
<br /> ❑F�e�roof,cedar ❑Restorat(on ❑Water Damage Minnetonka,MN 55345
<br /> ❑Re-roof,othel'(speclfy) ❑Siding ❑Olhe�:(speC'ify) Phone: 952-471-0590
<br /> Fax: 852-471-0682
<br /> w(s) __ www.minnehshacreekora
<br /> Estlmated Construction aluation of Project(exclu irtg land) $
<br /> APPLICAN7 ACI�WOWLEDGEMENT:
<br /> • Agrees to provlde all information required or requested by the Building Department;
<br /> + Certifies fhat the information supplied fs true and c�rrect to the best af hislher knowtedge. The applicant recognizes that they are
<br /> sofely responsible for submitting a compfete appiication being aware thet upon fallure ta do sa, lhe staff has no allemati�e but fo
<br /> reject il uMil it is complete;
<br /> • Some or all of lhe informatlon Ifiat you are asked to provide on this applicabon is dassified by State law as either private or
<br /> confidential. private data is informadon which generally cannot be glven to ihe publlc bui can be given to the subject oF the data.
<br /> Confidential data Is information which generally cannot be given io either the public or the subject of the date. Our purpose and
<br /> infended use of this intormation is to annuafty update our records snd records oF other governme fal agencies required by law. if
<br /> ou reFuse to su I the i rmalion tha a liption ma not be issued.
<br /> Applicant's Signature: � bate: � �
<br /> Ownar's Signature� Date:
<br /> Lasl Updaled:January 201 B
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