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� - Ci of Oron � I'� <br /> tY o <br /> Building Permit Application for Maintena ce / Renov�tion <br /> (windows, doors, siding, r�-roof, �tc.) <br /> ,�"o� Manl�BQ g�. REC�IVED <br /> ermitnumber: � / fJ7�J7 <br /> 0 � Crystal Bay, MN 55323-0066 e��W�; � �_ _ .3 <br /> ' a s�,ee:A�,,►��: JAN 2 9 2013 ����by: <br /> ��g '. �t+'� 2750 Keliey Parkway ���� <br /> $exd� Ornno, MN 55356 (�Y 0�ORONO �� <br /> --� �,..._ Q <br /> Main: 952-248-4600 Fax: 952-249-48i6 T ��F�� / � �� %O <br /> �w.ci.orono mn u� <br /> This appllcation form rnust be comp�eted in full and all required info tion must be submitted. <br /> GENERAL INFORMATION: 2 5�p�ete appll�atlons wlll be retumed. (Plea prinf) <br /> Job Site Addresat: J a 1��.�.� ��{,�, '��;�� <br /> ���th�s be a Parade oi Homes, Remodelers ghowcase Home a.o�her Dlsplay ome4 Yos No <br /> M 1^�,a apecie!evenf perm7!is�equired wNh pylce Departmer�t ana►CI(j,Cou»a7 ePprove/gp deya nr to the e►�nk Shultl�bus servioe wpl be <br /> reqWred unlesa epplkant demnnsnatea suMcie,rt on_a�Ye p���s a�b�. �n p��d eKenfs wrll not be aJlow�ed. <br /> CONTRACTOR!APPLICANT INFORMATION: <br /> Name: 1�. � A�t�Serv <br /> State License# �$C1309 3 <br /> Lead Certification Number. Expir tion Datie: 3I 31 <br /> �'AT- o� o�S 3 -1 Expi tion Date: t���5 <br /> (1f�r►Mwk on hornea ihet„yere eonstroci�ed prlor to 197d -- <br /> Phone: (05 I- oZ -y� `} (office) - <br /> Mailing Address: � .. �� �e� Ci (�I�) <br /> Contact Person: �� ; �, ZIP: S I <br /> Email and/or Fax: APP���nt is: n / Horneowner �crrd.a,.� <br /> PRQPERTY OWNER INFOR ATION: , <br /> Name: �S <br /> Phone (day): ' O� <br /> Address: LSi ' <br /> Email and/or Fax C�� ZIP: . <br /> ,. , <br /> RROJECT INF�RMATION: -- _ _ <br /> Type of Project; -__ . -._.__ <br /> ❑ Door(s) ❑Remodel A^Y�rth movs n!may requtre <br /> ❑ Fire Damape MCWD review d�p�m�; <br /> ❑Re-roof,aaphalt ❑ Repair Minnehaha Creek Watershed Dlstrid(MC�fp),_,,_ - <br /> _,. ❑Sb��Damage. :. _ .._ _..-_ �- 1�8202 Mlnnetonk8 Bfvd`'" <br /> ��. : .�. ...... _ <br /> Re�+oof;cadar ❑Restoration ❑Water Damage Deephaven,�1AN 55391 <br /> ❑R�roof,other(spocly) ❑S;�f� ❑��: (s���) Phone: 952-471-0590 <br /> Fax: 952-4�1-0882 <br /> ��n��s� yvu�yi r.minnehahacreek ora <br /> Overall Pro act Descriplion: � � � <br /> Estimabed Construction Valuation of Project excluding land s <br /> � <br /> APPLICANT ACKNOWLEDCiEMENT• I <br /> • A9►'aes to provide ell informatlon requlred or requested by the Buikling Department; <br /> � Certl6es that the information supplied is true and con�ect tp�}� �gt of his/her know�edge, The epplicarrt reoognlzes that they <br /> e�e so�ely ►esponsible for submitting a complete app�ication betng aware thal u <br /> but to reject it until it is oomplete; Pon faiture to do so, the staff has no aHernative <br /> � Some or all of the Information that <br /> oorrfidenlial. P�ivate data is informa�t�on whlch generaplly can�ot el glven�to the publ csbut can be 'ig ���e�sub P��',or <br /> data. Confide�tiel data is lnfiormatio� which generally cannot be � jec:t of e <br /> P�rP�e and irrtended use of this Informatlon is to an�ually update ou�records antl r��r,�d$a�he�'9a mmeMal�� nci,r <br /> ►e ulred b law. If ou refuae to su I the infomiation, !he lication ma not be issued. � � <br /> �oolicant's Sian8lure• p,r� ' <br /> oatg: a�� <br /> Z 'd 06T9�G9TS9 3�Ih?J3S 1IW213d Q R S I� T i ��i £i0Z 6Z UeC <br />