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. . <br /> City of Orono <br /> Building �ermit /�lpplication for IVlaintenance / �t�novatian <br /> {windows, dpors, siding, rewroaf, etc.) <br /> lvlailing Add�ss; Permit number: � "���'� <br /> ��y,a�.� F'O Box 66 l <br /> Crystal Bay, MN 55323-0066 Date received' ��—�8�� <br /> � � Strset Address= Received by: <br /> ��.� 2750 Kelfey Parkway Pl�n revlew fee�_ <br /> ��{�y� Q$�e Orono, MN 55356 <br /> �� ��!3. �C <br /> Tofal�ee: <br /> Main; 952-243-4B00 Fax: 952-249-4616 ww1H cj.grono.mn.us <br /> This applicatibn form must be completed in full and all required information must be submit�ed. <br /> Incomplete appllc�tions will be returned. (�'/ease print) <br /> GENERAL IIdFORMATION: ,, _ I <br /> Job Site Address: � �� ��11�t �L��W �C►U`� <br /> Will thls be a Parade of Hornes, Rempdelers Showc�se Home or other Display Homp7 Yes ❑ No <br /> ff y�s,a special event permi'�Is repulred w/th Police Departm�nt and Clty Council approva160 d&ys prlRr[o the event. ShuPUe Bus ssrvlce will be <br /> required un/ess applicant demonstrafes sufl7clen't onsite parking is availablg. lVon-pemtitfed events w!/!not be allowed. <br /> CONI"RACTOR 1 APPLICANT INF�FtMATION: <br /> Name� t�txl�o�\ ��Av�i�,Cs�r� <br /> State Licetlse# $�13oq$ N �Xp��t�on �ate: 3�3 f <br /> Lead Certification Number_ (�j�?� �"�-a g3 �� _ EXpiration Date: Lf f J� <br /> (for work on homes that were construoi�ed prior M�978 cefl <br /> Phone: (QS�� oZ(p�{--4•0�'$'" ,� (office) ( ) <br /> Mailing Address: , . � " " ��s,} C�YY� � �. �IP: SS 11 <br /> Gontact Person: Applicant is: ontract / Homeowner tc���ie one) <br /> Emall andlor Fax: <br /> PROPERTY OWNER iNF012MATiON: <br /> Name: i �\ � r U.Y`i� <br /> Phone(day): �.� S� <br /> Address: Ciiy: ZIP� <br /> Email and/ar Fax <br /> PR�JECT INFORMATIQN: <br /> Type of Project� Any earth movement may require <br /> ❑apo�(s) MCWD review 8�p�rmits: <br /> Q Remodel ❑Fire Damage Minnehaha Creek Watershed District{M�WD) <br /> ❑ Re-roof,asphalt [1 Repair []Storm Damage 18202 Minnetonka B�vd <br /> Deephaven, MN 5539� <br /> 0 F2e-roof,cedar ❑ Restoration �Water Damage Phone: 952�71-Q590 <br /> �.]R�roof,4ther(specity) �]Sidfng ❑Other: (specify) F�x: 952-471-U682 <br /> �Wlndow(s) www minnehahacreek.orp <br /> Overall Project Description: p� W;�{.OWS l.v ' r� �CJ1C� � <br /> Estimat�d Gonstcuctlon Valuation of Project(excluding land) $ /Q .� <br /> APPLICANT ACICNdWLEDGEMENT: <br /> . Agrees to provide all information required or requested by the�uilding Depgrtment; <br /> • Certifies that the information supplied is trus and correct to ihe best of his/her knowledge. The applicant reoognizes that they <br /> are solely responsibl�for submitting a compleie application being�ware that upon failure ta da so, the staff has no alternative <br /> but to rejeCt it until it is complete; <br /> . Some or aH af the information that you are asked to provide an this appiic�tion is classified by State law as either private ar <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 ciata is Information which genersAy cannot be given to either the publie or the su4ject of the data. Our <br /> purpose and sntended use of this information is to annual{y update our �ecords and records of other governmental agencles <br /> re uired b 1aw. If ou refuse to su I the fnfnrrnation,the a lication ma not be issued. <br /> /aoolicani's Sianature:� �� Dafe: �(7�� �� <br />