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City of Orono <br /> Building Permit Application for IVlaintenance / Renovation ;� <br /> ' (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �,�,� PO Box 66 <br /> � �. 0 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a �� 3r��� s, Street Address: Received by: <br /> '$�,� e�34" ti <br /> � �� 2750 Kelley Parkway Plan review fee: <br /> L�kESHo4� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us - <br /> ',: <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) ;� <br /> GENERAL INFORMATION: _ -- <br /> Job Site Address: '` � �� �� �;� <br /> Will this be a Parade of Homes, Remodeler Showcase Home or er Display Home? ❑ Yes No ��. <br /> /f yes,a special event permit is required with Police Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficienf on-srte parking is available. Non-permitted events will not be allowed. :�� <br /> CONTRACTOR/APPUCANT INFORMATION: t;� <br /> Name: ' <br /> �„ <br /> _>� <br /> State License# Expiration Date: ;�� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were consfructed prior fo 1978 <br /> Phone: (office) (cell) °''� <br /> Mailing Address: City: ZIP: t� <br /> Contact Person: Applicant is: Contractor / Homeowner �Circle One) 'k <br /> Email and/or Fax: <br /> M1�., <br /> PROPERTY OWNER INFORMATION: , <br /> Name: b Ct �! �L� -�k � `�� <br /> Phone (day): _ - � <br /> Address: �1��� �.�v 'i�[�( (Q City: �G ' �, ZIP: �j,3sf�, <br /> Email and/or Fax � • ��' <br /> clonn�as+v,a�hv�Frna��l .wrvi ;� <br /> PROJECT INFORMATION: <br /> �i <br /> Type of Project: Any earth movement may require ;�; <br /> ❑ Door(s) ❑ Remodel MCWD review&permits: `�� <br /> ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) � <br /> �Re-roof, asphalt ❑ Repair �Storm Damage 18202 Minnetonka Blvd � <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage PhoneaV952-4N1 05 01 '" <br /> ❑ Re-roof, other(specify) ❑Siding ❑ Other: (specify) Fax: 952-471-0682 ` <br /> ;;:� <br /> ❑Window(s) www.minnehahacreek.orq �� <br /> � <br /> Overall Project Description: (,LY �� � a ' - p � Q.v�c� c2,✓��� " � � <br /> Estimated Construction Valuation of Project(excluding land) $ �dp `� <br /> ':3 <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 knowfedge. The applicant recognizes that they <br /> are solely responsible for submitfing 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 /> '. <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 refu e to su I the information,the a lication ma not be issued. <br /> �__ s <br /> ApplicanYs Signature: �' . Date: � �� ; <br /> - °1',. <br /> Last Updated: 08-09-2011 <br /> ,,,; <br /> _ -ay <br />