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) <br /> City of Orono Z�� �� <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> �_ ,� Mailing Address: , � ,r <br /> /�g,�,j�.\ PO Box 66 Permit number: ,�Q 1� �' �L�.�i 3 <br /> 0�� Crystal Bay, MN 55323-0066 Date received: � �o�- <br /> ll ' � <br /> �� <br /> ��a l�`� J�,��' �, � StreetAddress: Received by: � � � <br /> �'F,L �����Gti� 2750 Kelley Parkway Plan review fee: --"' <br /> �ESHo� Orono, MN 55356 <br /> �-- <br /> o arFe���;>� _ K <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn. s� 5 i$ � � f' <br /> This application form must be completed in full and all require � ormation mus submitted.�������� <br /> Incomplete applications will be returned. (Please print) ���rvuv� <br /> GENERAL INFORMATION: �� �� �� �� �� � �� -- � <br /> Job Site Address: � �) <br /> j-�v��l <br /> Will this be a Parade of Homes, Remodelers Showc se Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Polrce Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. IVon-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Sv0��,or ��� � �--�✓ ,�.%.- .SPrI/��le S <br /> State License# � % Expiration Date: � - � � _ j <br /> Lead Certification Number. � -L( �� �2-� Expiration Date: S'-ZE -- (� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: _ t�y K- g y (office) �j (�_- �_ -�y 7� (cell) <br /> Mailing Address: p City: e G-, � ZIP: ✓j <br /> Contact Person: k 5��,� 2Vrs ' Applicant is: ontracto 7 Homeowner (Circle One) <br /> Emailand/orFax: � �vPS�,��% 5����r%",v� - (���F Co ,., l��' _ cl) cZ, -p�YD <br /> PROPERTY OWNER INFORMATION: <br /> Name: �' � ' u " <br /> Phone (day): �; r�- q _ � <br /> � <br /> � Cit � ' �� <br /> Address: � i �( � �;�0.� �i�W�va� ,�'r,� Y� �'%�'f���Si�// ZIP: �"�"� y <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 B 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) www.minnehahacreek.orq <br /> Overall Project Description: �� y ; r�r` ;��.,,,� r��,,,r� , G�T� �,,.� /'u,/1;` _ <br /> Estimated Construction Valuation of Project(excluding la�d� j -__ <br /> APPLICANT ACKNOWLEDGEMENT: � ��'� � � 3 � , � I ������ � ���� <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 /> ApplicanYsSignature: �l/ Date: �� _" �`�� <br /> � <br /> Last Updated: 08-09-2011 <br />