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<br /> City of Orono i4 .���ry,
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<br />� Building Permit Application for Maintenance / Renovation '` ���� �.�
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<br />��.- (windows, doors, siding, re-roof, etc.) ��
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<br />��; Mailrng Address: Permit number: 02-�! i�(�/�4� ��
<br />�'` �,L,0,� PO Box 66 �'
<br />� 0 �, Q Crystal Bay, MN 55323-0066 Date received: �v —��l—� ��
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<br />� - ,a ��� �.': �, i Street Address: Received by: �
<br /> ; �'.�c�L a`�� Gti� 2750 Kelley Parkway Plan review fee: ��
<br /> x � `�gEs��`'� Orono, MN 55356 � �
<br />�: —� Total Fee: �p�d,�� �'
<br />�� Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be submitted. ¢
<br /> �' Incomplete applications will be returned. (Please print)
<br />��: GENERAL INFORMATION: �n
<br />.-" Job Site Address: � - ,v
<br />�m` Will this be a Parade of Homes, emodelers Showcase ome or other Display Home? ❑ Yes No #
<br /> If yes, a special event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus ice will be �
<br />""�" required unless applicant demonstrafes sufficient on-site parking is available. Non-permitted events will not be allowed. �
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<br />�:; CONTRACTOR/APPLICANT INFORMATION:
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<br /> Name: �S�� ;r
<br />� � State License # �(, ��-]� Expiration Date: /S�j� �
<br />�}: Lead Certification Number: ��,� ��5=l Expiration Date: � � �
<br />�,; (for work on homes that were constructed prior to 1978
<br /> 4�"� Phone: `7C� 3-=L(�'7—� (office) (cell
<br /> )
<br />.�� Mailing Address: ����-� 5������ � �i City: �fJ��� �y����� ZIP: ��—�� �
<br />� Contact Person: A licant is: ��T�r / Homeowner
<br />�> ���//v ��t'�_��,.� pp (Circle One)
<br />,���, Email and/or Fax: —�
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<br /> � PROPERTY OWNER ORMATI N: ��
<br />�`". Name: �G�•,� l�d, < S
<br />��; Phone (day): ��,— 7� I--(��� � �
<br />� ; Address: �'j G6 �� � f C�>�.,� �.� City: dc','� ZIP: �
<br />.�< Email and/or Fax '`
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<br /> PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require ��
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<br />�' ❑ Door(s) ❑ Remodel MCWD review &permits: �
<br /> ❑ Fire Damage �
<br />�� Minnehaha Creek Watershed District(MCWD)
<br /> � �2e-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd ,�
<br />�„� ❑ Re-roof, cedar Deephaven, MN 55391 ,�
<br /> ❑ Restoration ❑Water Damage �
<br />��� ❑ Re-roof, other s ecif Phone: 952-471-0590 ��
<br />_ ( p y) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
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<br /> ❑Window(s) www.minnehahacreek.orq �''
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<br /> Overall Project Description: ��� �g - � — � �� � � 1- �_ , � ���.�� - �
<br /> Estimated Construction Valuation of Project(excluding land) $ `-� �
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<br />� APPLICANT ACKNOWLEDGEMENT: �
<br /> <m • Agrees to provide all information required or requested by the Building Department; k
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they
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<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 all of the information that you are asked to provide on this application is cfassified 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 of other governmental agencies �
<br /> re uired b law. If ou refuse to su I the information, the a lication ma not be issued. ,
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<br /> Applicant's Signature: ' Date: �•— �— .
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<br /> Last Updated: 08-09-2011 �'�
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