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. . <br /> City af 4rono <br /> Building Permit Appfication for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> l_� Mailing Addrvss: Permit number: p� ,—d � z <br /> �.�Q,�,� PO Box 66 <br /> �O � Crystal Bay, MN 55323-0088 Date received: � <br /> ,, � �,;, Street Address,- Received by: <br /> �'�,�, ' / 2750 Kelley Parkway Plan review fee: <br /> � <br /> `�,�,��'/ Orono, MN 55356 <br /> �� r-� Total Fee: pf o�7 � <br /> Main: 952-249-4600 Fax: 852-2A9-4616 vwvw.ci.arorto.mn.us <br /> This applieatian form must be campletec�in full and all required iriformation must be submitted. <br /> Incomplete applications will be returned. {P/ease print) <br /> GENERAL INFORMAl10N: <br /> Job Site Address: �'" ! r. <br /> Will this be a Parade of Hcmes, emodelers Showcase ome or other Display Home7 Yes <br /> l�yes,a specis/evenf permiP is required with Police Department and City wunci!approva!60 days pnor to the event. ShulNe bus service wi!!be <br /> �quired un/ass applicant demonstraiss sufficient on-sife par/vng is available. Non�em'iifted events wi11 not be allowed. <br /> CaNTRACTOR/APPLICQNT INFORMATION: <br /> Name: i�c� � v_ �'`�'i� �..�� �,. <br /> State license# ,r,� ' r Expiration Date: '3•.�/� ����a�., <br /> Lead Certification Number. Expiration Date: <br /> (for work on homes ihat we�consbv ted prlorto?978 <br /> Phone: � ,�- " �.�,/.. ' (office) - ,�'�y •- 7 f (cell) i <br /> Mailing Address: ;' .�� City: ZIP: —' �' s"' <br /> Contack Person: ,,. ' ,�> Applicant is: Contractor ! Homeowner (Clrole One) i <br /> Email and/or Fax: - r 7 <br /> PROPERTY OWNER INFORMATfON: � <br /> ...– <br /> Name: �-. � <br /> Phone(day): � � � � � <br /> Address: C��Y� Z�P� � <br /> Email andlor Fax , <br /> PROJECT 1PIFORMATION: ; <br /> Type of Project• Any earth movement may require <br /> � MCWO review 8�permits: � <br /> ❑Door(s) ❑ Remodel ❑Fire Damage Minnehaha Creek Watershed District(MCWD) � <br /> e-roof,asphalt ❑ Repair ❑Storm Damage 18202 Minnetonka Slvd <br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage �ePhaven, MN 55391 <br /> Phone: 952-471-0590 � <br /> ❑Re-roof,other(spacify� ❑Siding ❑Other.{specify) Fax: 952-471-0682 <br /> ❑Window(s) �n�ww.minnehahacreek.ar� <br /> Overalt ProJect Description: ' •(..-'., c�C► � ' <br /> Estimated Construction Valuativn of Pro'sct(excluding land) $ ,�Ci � <br /> APPLICANT ACKNOWLEDGEMENT: , <br /> . Agrees to provide all information required or requested by the BuildinQ Department; <br /> . Cert�es that the information supplied is true and correct to the best of his/her knowledge. The applicaM recognizes that they <br /> are solefy responsible for submitting a compiete application being aware that upon fai{ure to do so, the staff has no alternative <br /> but to reject it until it is complete; ' <br /> . Some or all of the information that you are asked to provlde on this application ia classified by State law as eiiher 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 � <br /> data. Confsdentiat data is infom�afion which generally cannot be given to either the public or the subject of the data. Our i <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 n, � lication ma not he issued. � <br /> Applicant's Signature: --�-' Date: � � i <br />