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JUN/08/2017/THU 09: 45 AM Elder Jones Building FAX No, 952 854 4909 P, 002/002 <br /> . <br /> � City of Orano <br /> Building Permit Application for 1111aintenance / Replacement I Remodel — Residential ONLY <br /> (i.e.windows, doors, siding, re-roof, etic. � NO STRUCTURAI� �XPANSION) <br /> �O�a Mailing Address: Permit number: .Z <br /> PO Box 66 <br /> Crystal Bay, MN 55323-OQ66 Dafe received_ <br /> Streai Address: Racefved by: <br /> � � 2750 K�lie Parkwa ._.--- <br /> ��, G� Y Y Plan revfew fee: <br /> � Orona,MN 55356 <br /> �xFSHo � Total Fee: � ��. �� <br /> Main: 952-249�4600 Fax: 952-24�4616 www.ci.orono.mn.us <br /> This applicatlon form must be completed In full and all required information must be submitted_ <br /> Incomplete applications will ba returned. (Please print) <br /> GENEFtAL INFORIIAATION: � <br /> Job Site Address: 0�.(�� �{r`((,(� S`f". <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other tiisplay Home? Yes No <br /> !f yes,a specia/even��A�mJ+�R�an�are�i wirn p�lir:A Deaertment end Citv Council approvaf fi0 days prlor to the�v�nt. Shutfle bus ae�vice will be <br /> raquin9 Home Depot USA, InC. �9 rs avallable. Non-permftted ev�nts w111 notbe allowed. <br /> CONTRACTOR l� 2455 Paces Ferry Road <br /> Name: Atlanta, GA 30339 <br /> State License# Phone 763-542-$826 Expiration Date; <br /> Lead Certification f �ic # BC 147263 Exp.3/31/2018 �0�a7(�y a Expiration l7ate� -j ..�j <br /> (for work on homes fhat were constructed prior fo i978 , <br /> Phone: (cell) (office) �jsZ,',�j�J�,v� 7 �'L�,�,�� <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: ontracto / Homeowner (Clrcle One) <br /> �mail and/or Fax: ��,;�.���d��cnrn,�t �G(IVY� <br /> PROPERTY OWNER INFORIVIATION: � <br /> Name: � � U <br /> Phone(day): Gj�'2-� �'l�7-��87� <br /> Address� City: ZIP� <br /> Email and/or�ax� <br /> PROJECTINFORMATI�N; Qverall r�ectdescription: <br /> Type of project: Any eaCth movement may also requlre <br /> ❑Door(s} �Remodel �Flre Damage <br /> MCWD review&permits: <br /> �Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creelc Watershed Dlstrlot(MCWD) <br /> 15320 Mlnnetonka glvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Minnetpnka,MN 55345 <br /> ❑Re-roo#,other(spec[fy) ❑Siding ❑Other:(specity) <br /> Phone: 952-47�-0590 <br /> Fax: 952-471-0682 <br /> �Nindow(s) a�(N� � � ,�vw�,�Cr�ghahacresk.orQ <br /> Estlmated Constructton Valuation of Project(excluding fand) $ -' <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provfde all information required or requested by the Building Department; <br /> . cartifies that the informatlon supplied is frue and correet to the best of his/her knowledge. The applicant recogni�es that they are <br /> solely responsible for su6mitting a compl�te applicatlOn being aware that Upon falEure to do S0, th9 Staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the Inform8tlon that you ere esked to provide on this application is classified by State law as either private or <br /> confd�ntial. Privat�data is infarmation which generally cannot be given to the publle fout ean be glven to the subject of the da1a. <br /> ConfldentEal data is information which generally cannot be given to eithmr th� public pr the subjeCt of the data. Our purpose and <br /> intended use of this information is to annually update our rBCOrds and recoPds oF other goverrlmental agencies required by law. If <br /> ou refuse to s I th ' formation the a ication ma not be issued. <br /> Appficant's Signature� l"r"�� Qate: ���f r / <br /> OWner's Signatur . Date� <br /> Last Updated:January 2016 <br />