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<br />� City of Orono �� �}� N
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<br /> ' � �` F�ki �a".
<br />� , ' Building Permit Application for Maintenance / Renovation ���� '�
<br /> r� (windows, doors, siding, re-roof, etc.) �
<br />�' Mailing Address: Permit number: a �� � � D� 2 S� �
<br />�„�� �v�,� PO Box 66 �
<br /> Q � Q Crystal Bay, MN 55323-0066 Date received: 1�--��- �� ,���
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<br /> ' �a �-�' �, Street Address: Received by:
<br /> �
<br /> g� �'�t t "��„ �ti 2750 Kelley Parkway Plan review fee: �
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<br />�";��' `�gESHo�''� Orono, MN 55356 -
<br /> --� �-
<br /> Total Fee: -:.
<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) k�
<br /> GENERAL INFORMATION: _
<br /> Job Site Address: �� � �Q� Lj,�/�' ,j]j�/(/'� �/,� /���L' �,(� ss �G �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or ot er Display Home? ❑ Yes No
<br /> If yes,a special event permif is required with Police 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. Non-permitted events will not be allowed.
<br /> tt,� CONTRACTOR/APPLICANT INFORMATION: ��
<br /> Name: Gl�/L-L%/}��/j C/2�'� �
<br />,:;
<br /> State License# Expiration Date: ---� �
<br />� Lead Certification Number: ,`-- Expiration Date: -� �
<br />��: (for work on homes that were construcfed prior to 1978
<br />, , Phone: `2o fi �2'J 0 O G ( (office) (cell) �
<br /> k " Mailing Address: ��5� p�rl(,:� ��G �-/ City:� D'�.�;�K� (�lL� ZIP: 6Vj�l,' �5--3C�/�
<br /> � Contact Person: o A licant is: Contractor / Homeowner a�
<br /> "�` ��r� �/���� pp (Circle One)
<br />�� Email and/or Fax: �;���``f�'e e� Q� � `j� ���'�, �ply�
<br />�' - 1 �
<br />�� ' PROPERTY OWNER INFORMATION: �
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<br />� Name: C/JSCZ} /2(/ ,�
<br />�' Phone da (��Z ��- � � _ �
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<br />�:., Address: /qg� �/�T-�5� /�lr�'�V[�`� City: ��l%��Z�T/� ZIP: �S�, �;
<br />� Email and/or Fax � ��
<br /> ,, ��
<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 r�
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 ,�
<br /> Phone: 952-471-0590 1'
<br /> ❑ Re-roof, other(specify) ❑ Siding � Other. (specify) _ Fax: 952-471-0682 .�r�
<br /> ", ❑Window(s) �(GS ��o��L/�U"�S—�4C'�, �^'�'�`N.minnehahacreek.orq +�;.
<br />� Overall Project Description: Q��/�i,L j"w�J LXrG,�-?/'p/� �7�'G/C � d�'1/ �DoQT--/� S/,IJJ� ��
<br /> q'` Estimated Construction Valuation of Project(excluding land) $
<br />,,, *-.
<br /> APPUCANT ACKNOWLEDGEMENT: �
<br /> a. �. • Agrees to provide all information required or requested by the Building Department; �.�
<br /> c�
<br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they u�
<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; �y,�
<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 enerall cannot be ��
<br /> g y given to the public but can be given to the subject of the �;t�
<br /> data. Confidential data is informa ' Fj which generally cannot be given to either the public or the subject of the data. Our r��
<br /> purpose and intended use of this infprmation is to an "�Ily update our records and records of other governmental agencies ''
<br /> �
<br /> � re uired b law. If ou refuse to u I t informatio , t e a lication ma not be issued. ,�
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<br /> ApplicanYs Signature: Date: �� ��Q,�Ge��%� �''
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<br /> Last Updated: 08-09-2011
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