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�.��y v� vi u��v <br /> Buil�ling Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ���O^' MailingAddress: Permit number: O��I -U I7�� <br /> � `VO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �O��5�� <br /> E � 4 � Street Address: �..�— eived by: <br /> ' 1 2750 Kelley Parkway � � Plan review fee: �/y-�/7..3 <br /> : � � <br /> �� � � Orono, MN 55356 � �� / p <br /> ��ESNO�� � �� Q�{o.0 9 - <br /> �—_ Total F e: -" <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � -j .rj ,. "-d �-) <br /> This application form must be completed in full and all required information must be submitted. t,�,_,<1 ��/i��J�,- <br /> Incomplete applications will be returned. (P/ease print) � <br /> GENERAL INFORMATION: <br /> Job Site Address: ��soS� /V1./a-P�•(� r�G (J�-�- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If 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 sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: '' —' <br /> 't+ C ' l ��i f: t_� � v��.. . <br /> State License# �� (0 3-�`�S� ^ ' Expiration Date: �j� j�, <br /> Lead Certification Number: �/�,��-� ����yy _� Expiration Date: � � � <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (�/ _ �� .� a (office) L/,�l—���•f__ ��yG <br /> Mailing Address: -3�,� �a�AP�«, • � � z_ S, ` � r _3 City:Lvcb ZIP: �'S�' � <br /> Contact Person: (��..��N� ���.`���� Applicant is: ontractor / omeowner (CircleOne) <br /> Email and/or Fax: �t�;�r�.� 2 �r.xr. . ��•,, � !«� (��/� rc!�-c��?'l <br /> PROPERTY OWNER INFORMATION: `(� I <br /> Name: �r �c: }- �ur eY� �Nc-c.i.ti 6Sc�� <br /> Phone (day): y 5� — ' / - �D� <br /> Address: 0'��05 ��r/�r�����- �-cz��� City: ��[' �1 S;or ZIP: SS .�j �3 f <br /> Email and/or Fax: �._... <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review 8 permits: <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <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 land) $ D <br /> APPLICANT ACKNOWLEDGEMENT: <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 in rmation,t a lication ma not be issued. <br /> Applicant's Signature: /ttL � Date: /� ' O <br /> Owner's Signature: Date: <br />