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• � - City of Orano <br /> �3uilding Permit �ppiication for Ma�ntenance / Renavation <br /> (windows, doors, sid�ng, reMraof, etc.} <br /> MalfingAddress: Permit number: . �I7"�7 <br /> 0.�,Q,�Q PO Box 66 � <br /> Crystal Bay,MN 55323-0066 Da�e•recsived� � <br /> ,, Str�etAdd�ss: �Ived by: <br /> � a7�o��iey p�+ay aiar,re�rew�ae: � <br /> � �° Orono, MN 55358 � <br /> �o�Fee: � 59, g� <br /> Mein: 952-24Q-4600 FBx: 952-249-4616 www.a.c�rnno.mn.us � <br /> 7his appiication�orm must be compfeted in fi,lt and aU required ir�oRr►ation must be submitted. <br /> Incomplets appfications wllE be returnec�. (P/ease prin#) <br /> GEN�RAL INFORMATION: � � �� � _►I� � <br /> Job Site Address: �l4- � <br /> Wtll thls be 8 PaT�lde of liomes, Remodelers S se Home or ot Disptay Hort�e? Yes No <br /> My�es,a BperJal event permit is rgpulred wfth Pofics Aep�rtment and GYy Courrdl app�ovaJ 60 deys prlor to 6he even� Shutfle bus aervJcs wl11 be <br /> requirod unless appliCeM dAri'�onstrafies suffident on-slte par#ing!s avallatrle. Nanyo6l�Jfted everrts wilf not be allowed. <br /> CQNTRACTOR!APPLICANI"INFORMATiON: <br /> Name: 1�G�a.\ �y��'C'CSer� , <br /> State Ltcense# �sC.1309$ Expiratian D�te: �,(3 L <br /> Lead CeRlfica#ion Number: �j#�"�� a�-�$�_�� Expirdtion Dste: +{ <br /> (fbr wo�fc an homes thaf w�er8 consbuct�d pr�or to 9878 <br /> Phone: (pS1+ o�,(�y-��O Sd- r�yA.r� (office) (celq <br /> Ma(Iing Addtess: � " •• �,�.t�, � City: � e ZIP: S <br /> Contacf Person: Applicartt Is: ntwa ,/ Homeawner ca���a o�) <br /> Emai4 and/or Fax: <br /> PROPERTY OIMINER INFORMATIQN: <br /> Name: � -�'� <br /> Phone(daY)= l o�•S l O <br /> Address_ City: ZIP_ <br /> Email and/or Fax <br /> PROJECT IN�ORMATtON: <br /> Type of�roject: Any earth movement may require <br /> � Door(s) ❑Remodsl [�Fre[]�msge �����`����' <br /> Minnehaha Creek Wat�rshed Dtstrict(MCWD) <br /> [� Re-rpof,asphalt ❑ftepait �Storm D�mage 18207 Minnetonka Blvd <br /> Deephraven,MN 5�391 <br /> ❑Re-roCf,Cedar C]Restoration ❑Water Damage phane: 952-471-0590 <br /> ❑Re�roof,othar(sp•c�ry) ❑Siding [,�Other:(s�fj+) - Faz: 952-47i-0682 <br /> p� 3 ��plUwS �%� www.minnehshacreek.or� <br /> ❑1Nndow(s) � • - <br /> � �. <br /> Overa[f Project Description: <br /> Estimatsci Constructton Valuation of project(excluding tand) $ ol '3 .� <br /> APPL.tCANT ACKNOWLEDCxEMENT: <br /> • Agre�s to provlde al!infiarmation requtred or r�quested by the Bullding Department; <br /> • Carf.fffes that the +ntormation supplied is true and correct to the best of h[s/her Isnowledge. The applicsnt recognizes that they <br /> 8t�6 soleiy responsible loor submitting a complete apptication being aware fhat upan fadure t,o do so,the staif has no aitemstive <br /> bu#to reject it untiE ik is complefe; <br /> • Some pr aEl of the iriformatipn that you are 8Sl�d to provid9 011 thL�applicati0tl IS classsf'ted by StBte law as either privaie or <br /> c�onfdentlal. Privai�e data 'ss 9ttformatlon which generalty cannot be ghren to the public but can be given ta tha subJect of the <br /> data_ Confidenfial dsta Is Information which generally Cdi�not be given to either the publiC or the subjeci Of the data. Our <br /> purpose and intended u5e af thls iniormation Ps to annually update our records 8nd records aF other govemmentsl agencags <br /> re uired b law. If ou re�fuss to su f the inform�tEqn the a IicaNdn ma not b�isse�ed. <br /> Aoolicant's Sianature: Date_ lJ� � �J� � � <br />