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City of Orono <br /> 3uilding Permit Application for Maintenance / Renovation <br /> � (windows, doors, siding, re-roof, etc.) <br /> �--- Mailing Address: Permit number: �� � b�d � <br /> /�,0,�. PO Box 66 <br /> �Q , Q � Crystal Bay, MN 55323-0066 Date received: 1'3�� <br /> I�� �� -�°`;. �) � � Street Address: Received by: <br /> .�, �ti � 2750 Kelley Parkway Plan review fee: <br /> �9kE8H��'/ Orono, MN 55356 � <br /> -' Total Fee: � �C�,9�j � �' <br /> Main: 952-249-4600 Fax: 952-249-4616 v;av�v�_c� oro��: _���n iis / .J � <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) � 2�i <br /> GENERAL INFORMATION: • ��' <br /> Job Site Address: ��7� �� �om 'R <br /> Will this be a Parade of Homes, Remodelers Show se Home or other Display Home? ❑Yes No <br /> If yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates su�cient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION• <br /> Name: � ' <br /> State License# 'Z�g� Expiration Date: � 3 �j <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: � _ office) s,,..-` (cell) <br /> Mailing Address: � � .t:,l.�,'„�c� (u City: � S;e,r-- ZIP: � <br /> Contact Person: v�,� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: KKO ��J � E q �o �;( {� ce��-•� <br /> PROPERTY OWNER INFORMATION: (� <br /> Name: 5u P �-�tc�Q rSt�✓� <br /> Phone (day): �rj�,_ ,�"�( – g�9 S <br /> Address: �.� � � �m� � City: ��Kp ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) (� Remodel ❑ Fire Damage MCWD review�permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) n�vvw.minnehahacreek.or� <br /> Overall Project Description: (Z,_,N,o c � rn�,✓1 <br /> Estimated Construction Valuation of Project(excluding land) $ ( 7� p� <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 his/her knowledge. The applicant recognizes that they <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 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 of other governmental agencies <br /> re uired b law. If ou refuse to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �— � <br /> Last Updated: 08-09-2011 <br />