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� ` I I I <br /> � I <br /> � �ity of �ro�no <br /> Building Permit�App! cation for Nlaintenance / �enovation <br /> (w� dows doors, siding, re-roof, et�.) <br /> � M'ailiPo B $fi• Peimit nurr�ber.: 7� <br /> Q� �`va Crystai Bay,MN 55323-006$ p8fi�rece � <br /> � �' tr�etAcld : E7eceived b. : <br /> 2750 ley ParlcwaY k�lan revie�(ee: <br /> ���o$�' � Orono.MN 55356 <br /> � 1'otak Fee: � ,�� <br /> Main: 952-249-�1600 gax: 852- 9-4616 ' rono.mn.us �� <br /> This applicatiQn#orm m st be oorihpfeted in futl and ait required informatton m be submitted. <br /> Inco�p[et�ap tica�tions wfll be returned. (Please print) <br /> GENERAL 1NFORMATION: �G�� n ` ��O�� � �I� ; <br /> Job Site Address: �v <br /> Will this be a Par�de of Ho�r�es,Ret#todelers howc�s�Home or o#her Display Nome? Yes No <br /> !P y�as,s BpeClp!event permit is required�Pol)Ce De�arbnent and City COuncll approval6p dqys pl1o�fo the ev�snt. ShutNe btl9 Servlce will be <br /> r�quired unJ68s sppllcant d �nstrates �ent on�lte parkrng is aveileb/s. Mon�ermitted evb»t�t wlll r7ot be allowed. <br /> CpNTRACTOR/APPLICANT INFORMATION. , <br /> Name: 1� \ �Ar� rSe,r� <br /> State�}cense# G13Q9 '3� ` Explration D te: 3 f 3, <br /> Lead Certification Number. (�j �' �j� $� � Expiration D�ate: y J�c _ <br /> (far wark on homss d+at we,e c�nstr�ra�ed pN to 7878� <br /> Phone: (oSl— o� —4•0 (office} (cell) <br /> MailingAddress: �9�p . 1 �• •. �,�- CjtY:�v;1 � �Ip: SStI� <br /> ContaCt Person_ Appiicant is: , ntrac�o� Homeowrter �a�e o,�o� <br /> Erttall and/or�ax: <br /> PROPERTY OWNER INFORMA710 : <br /> fVame: �t . <br /> Phone(d�y): 9$2• y = k 1 <br /> Address: � City: ZEP: <br /> Emaii and/or Fax <br /> PROJECT iNFORMATCON: <br /> Type of Project: Any earth ovement may require � <br /> 0 Door(s) ❑Remodel 0 FIrB Damsge M� ^�ew 8 perrnits: <br /> Minnehah�C k Watershed District(MCWD) <br /> ❑R�roof,asphalt �Repalr ❑Sform Damage 1$�d2 Minnetpnke Bivd <br /> ❑Re-roof,cedar ❑ReStorANon ❑Water D�mage Dee�haven, MN 55387 <br /> phone: 952-471-0590 <br /> [�Re-roof,ather(�pecify) ❑Sidin9 Q Other.(specify) FeX: 952-471-06$2 <br /> ❑Wtndow(s) www.mi hshacreek.nr <br /> Overail Pro sct Description: �CQ � lnri hp�C3W 5 �h �-2J��S � <br /> Estimated Canstructlon Valuatlon of ProJe (excludin fan $ Q7 �3�,0 <br /> APPL[CANT ACKNOWLEDGEMENT: <br /> . Agrees to provids afl ircFormation required vr requested by the Building De�rtment; <br /> • Cartifies fhat the lnformatian supplied is true and oorrect to the best of his/h�r knnwledge. Ti�e applicant►,�oognizes thst the� <br /> ar�solely responsibte inr submilfing a comgiete spp�lcatlon betng aware that upon failure to do so, the staff has no aftemstive <br /> but to reJect It unti{it is cvmpiete; <br /> • Some or alI of th� informa�ion that you sre asked fo prov�de on this appllcstlon is classiiied by St�ate taw as either private or <br /> confidential. P�ivate data la tnformatlan wh�ch ger�ecally cannot be given to the pubisc but can be giv�n to the subject of the <br /> data. Confidenta�l d�ta is 3nfqrrn�t9on whlch generaliy cannot be given to etther the public or the subject of the data. Our <br /> purpose and intended use of this ini�mation Is ta annually update our records snd records of other govemmental egencies <br /> ulred b law_ If u refuse to su I the inform8tion the a icatlon ma nat be issued. <br /> An�licanYs Sianature: Date: �d����'' � <br />