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� M <br /> Cl�y Of orOn� <br /> �uilding Permit Application for Ii�aintenance / Renovation ' <br /> (windows, doors, siding, re-roof, etc.� <br /> Mailing Address: Permit number: <br /> ��.,�,�'�� PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> � � ���, � Received by: <br /> ,� ,�.� �'� ,�,� Sfreet Address: <br /> 1��" > <br /> �'�, �; ����'�"�,���� ti� 2750 Kelle Parkwa <br /> �� � Y Y Plan review fee: <br /> �R����' �^�g�G Orono,MN 55356 <br /> k�sKo <br /> ��-- Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 ww�v.ci.orono.rrtn.us <br /> This app{ication form musk be completed in full and all required information must be submitted. <br /> Incomplete applicafiions will be returned. (Please prinf) <br /> GENERAL INFORMATION: �y��., <br /> Job Site Address: p��f ��O/2 �1`IG�C� <br /> Wifl this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a spec%a!evenf permit is required wifh Police Deparfinent and City Counci!approva!60 days prior fo the event. Shuffle bus service wd!6e <br /> required unless applicanf demonstrafes sufficient on-site parking is avaitable. Non-permitfed events wi!!not be allowed. <br /> CONTRACTQR 1 APPLICANT INFpRMAT[O • <br /> Name: �i/J/���SU�a� ,��e�/D�"s <br /> State License# �J � 7� Expiration Date: ,3�j � <br /> Lead Certification Number. �' _��3D -,� Expiration Date: ,S�p �Q <br /> (for work on homes thaf vvere consfructed prior fo 1978 <br /> Phone: ����39'%,�j�v {ofFce) (cell) <br /> Mailing Address: (Q pQ �' �j Ciky: ZIP: � <br /> Contact Person: ����fj�-�• 5��� Applicant i . Can ractor Homeowner (Cirde One) <br /> Email and/or Fax: ' fj��cS��-� � yy����.��� <br /> PROPERTY OWtJER 1NFORMATION: <br /> Name. ,G p�-'�/7 �j�Z <br /> Phone (day}: /� _� � � d,� <br /> Address: .3�jr� D`� �CJC.�i C��'/�jf��� ZiP:�J��IQ � <br /> Email and/or Fax <br /> PROJECT fNFORMATION: <br /> Type of Project: Any earth rnovement may require <br /> ❑ Door(s) ❑ Remodel ❑Fire Damage MCWQ review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑5torm Damage 182Q2 Minnetonka Blvd <br /> ❑ Re-roaf,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other(specify) �,Siding ❑Other:(specify} Fax: 952-47i-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overal{ Project Descrip#ion: (�- <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of hislher knowledge. The applicant recognizes that fhey <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or a!I of the information that you are asked to provide on this application is classified by State law as either 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. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this information is to annually update our records and records ef other governmental egencies <br /> re uired b law. If au refuse to supply the information,the application ma not be issued. <br /> ApplicanYs Signature: ���.[�C� Dake: ��� �� <br /> Last Updated: 08-09-2011 <br /> ���� <br />