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NOU-30 2011 14:30 From: 6785736615 To:9522494616 Pa9e:1�1 <br /> Cit� of Orono <br /> Building Permit Applicati.on for Maintenance / Renovation <br /> (windows, doors, sidin , re-roof, etc. <br /> Mailing Addr�ess: Perm1�number: O�� ��� '�J <br /> O�L�j�O PO Box 66 <br /> Crystal Bay,MN 55323-�066 Date r�ceived: - O— <br /> a � SheetAddr�sS: Recei�led by: <br /> '� E. 2750 Kelley Parkway Plan 'ew fee: <br /> '�tq����' Orono,MN 55356 <br /> T�� �: ��,3� <br /> Main; 952-249-4600 Fex: 962-249-4816 www.a.orono.mn.us <br /> This application form must be campleted�in full and all required information mus#be submitted. <br /> Incomplete applications will be returned. (P/ease p� t) <br /> GENERAL INFORMATION� <br /> Job Site Address: �`3�a� woo �, <br /> Wil�this be a Parade of Momes, Remodelers Showca Home or othe�Display Hor�e? ❑Ye� No <br /> yes,e speaa/evenf permit is required with Police Depa/trnent and City Council approval 60 days prior In the event. Shuttle bus seivice will 6e <br /> requiied unless applicant demonstiates suli5cient on-site pa/ldnq is av8i/eb/e. Nonpe►mitted�vents will not be allowed. <br /> .,... __. , , _ . .. <br /> _. .. <br /> . . ; <br /> �ONTRACTOR/APPLICANT INFORMATION: - <br /> Name: Si w�� C.�.S�c��..s n <br /> State License# q�,,� � �S�-� � �� E�cpiration Date: �4f �-�, <br /> Lead Certiflcation Number. Expiration Date: <br /> (for woik on homes thai were constructed prior tn 1978 I <br /> Phone: (Z S6l �oaa (o�ce) <br /> (cell) <br /> Mailing Addrass: lL'3 b� 1�-�-� l/L�R� ��.. City, �,��. s�� ZIP' �r �3^� <br /> CantaCt Person: ��,,�.��„�,`, Applicant is: Contrac�'r / hlomeowner �C1role One) <br /> Email and/or Fax: �„�, � ����� ������� S��� <br /> PROPERTY OWNER lNFORMATIt)N: <br /> Name: Q.l,.o...�A.� �,�,`�. <br /> Phone(day): � <br /> Address: V �- City: t7r o ZIP;"S'T 3 q <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Preject: My e ,rth movement m�y require <br /> ❑Door(s) ❑Remodel MCWD review 8 permits: <br /> ❑ Fire Damage Minnehaha�reek Wstershed District(MCWD) <br /> ❑Re-roof,asphalt ❑ Repair [v�'Storm Damage 1I8a02 Minnetonka 81vd <br /> [✓]�te-roof,cedar Q Restoration ❑Water Damage �eephaven, MN 55391 <br /> ❑Re-roof,other(specity) ❑Sidin hone: 952-471-0590 <br /> g ❑Other: (specify) Fax: 852-471-0682 <br /> ❑Window(s) . in eh ha .or <br /> Overall P�oject Desc�iption: � '���o�F 's y� _�o� � <br /> Est�mated Construction Valuation of Pro�ect(exclud�ng land) � � , �j 6� •�� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Departmerrt; <br /> • Certifies that the information supplied i�true and correct to the best of hislher knowledg . The applipr�t recognizes that they <br /> are solely responsible for submitting a complste application being aware that upon failu ' tv do so, ths staff has no altemative <br /> but to reject it u►rtil it is complete; <br /> • Some or all of the ir�formation that you are asked to provide on this application is class fled by State law as either private or <br /> oonfldential. Prnrate dats 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 cannet be given to either the p4blic or the subjed of the data. Our <br /> purpose and intended use of this iriformation is to annually updats our records and reoords of other govemmental agencies <br /> re uired b law. If u retuse to su I the information, he a lication ma not be issued.� <br /> w__��___u_ ne___a..__. / � 1 ` A� . w r�... I �1 1 �7A �� <br />