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City of Orono � ' " <br /> �-. t� + . <br /> ' Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: a(�/ l-s Q l � <br /> =�j,�,�. PO Box 66 �Permit number: 5` <br /> /� � � Crys ta l Bay, M N 5 5 3 2 3-0 0 6 6 Da te re c eiv e d: � �J � <br /> �'� �� Received by: <br /> �,a ����� �o� s, Streef Address: <br /> �',F,t � �� �ti 2750 Kelley Parkway Plan review fee: �4 <br /> � Orono, MN 55356 <br /> q'xESH�4 <br /> Total Fee: ��� ,� �� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us t: <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: . <br /> Job Site Address: ��,�%� ,� � �'S v�� � <br /> Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? ❑ Yes o � <br /> If yes, a special event permit rs required with Police Department and Crty 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 /> CONTRACTOR/APPLICA T INFORM TION: / � <br /> Name: � ` .� � _/` ' ��15 � ��� ��� T <br /> State License# Expiration Date: � _�/Z `.� <br /> Lead Certification Number: Expiration Date: _��T���- <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: �. �' ���� (office) � ' � � (cell) 4 <br /> Mailing Address: ��� City: �,./��� , ,� ZIP: - � � <br /> Contact Person: � ' A plicant is: n r�ac�� / Homeowner `�Circle One) a; <br /> Email and/or Fax: ����/���������� ;?� <br /> � <br /> PROPERTY OWNER INFORMA ION: I `: <br /> Name: /2������r�iG ��r`/So�C � <br /> ' <br /> Phone (day): �Z��'S'�/.��/ <br /> Address: ��� � ����L� City: �j�-j� ZIP:���'�L <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 x' <br /> ❑ Re-roof, cedar ❑ R toration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify} Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> �indow(s) <br /> www.minnehahacreek.orq <br /> Overall Project Description: ). �' ��, �— -� �, ��,� <br /> Estimated Construction Valuation of Project (excluding land) $ ���n�}� �� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the informafion supplied is true and correct to the best of his/her knowledge. 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 /> • 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 annualty update our records and records of other governmental agencies <br /> re uired b law. I# ou refuse to su I the information,th a licafion ma not be issued. <br /> ApplicanYs Signature: � Date: �/z�"/��// <br /> ��. <br /> Last Updated: 08-09-2011 <br />