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NOV-28-2011 13:45 From: 6785736615 To:9522494616 Pa9e:1�1 <br /> ���o`� Pa`'� \�� . <br /> � ��� �' C�ty of Orono <br /> Building Permit Application for Maintenance / R�novation <br /> (windows, doors, siding, re-roof, etc.) <br /> MailingAddress: Permk number: � 0��83 <br /> O�O�O : Crystal 8 y, MN 55323-0066 Date reoeived: ��'Z�— �� <br /> ,�� � Shest Add�ess: Received by: B <br /> 2750 Kelle y Parkwa y P l a n r e v i e w f e e: <br /> �� �� Orono, MN 55356 <br /> Total Fee: 3�+J c�l� �'� f' � o0 <br /> Main: 9 5 2-2 4 9-4 6 0 0 � F a x: 8 5 2-2 a 9-4 B 1 6 w w w.c i.o r o n o,m n.u s � � <br /> This application form�nust be completed in full and all �equired information must be submitted. `� <br /> tncomplete applications will be returned. (Please print) U <br /> GENERAL INFORMAT90N: <br /> Job Site Address: I�.S S � - <br /> Will this be a Parade of Homes, Remodelers Showcase Home o�other Display Home? ❑Yes ❑No <br /> liyss,a specia/evsntpermilis required,wi�lt Police Department and CityCouncil approval BO days priorto the event Shutde bas sen+iee will be <br /> iequired un/ess applicant demonsbates s�aent on-sf�e paiJcing is available. Non�ennitted events wlp no!be al/owed <br /> CONTRACTOR/APPLlCANT INFORMATION: � <br /> Name: `?�,ao� �a•n� .� � <br /> State License# � �C �q3(,1—(� Expiration Date: Z <br /> Lead Certification Numb�r: Expiration Date: <br /> (for r►rork on homes that were con�tructed prior tv 1978 <br /> Phone: (,ly��� oo,� (o�ice) (celq <br /> Mailing Address: �-� ' � : ,��r ciry: ,g ns�� Z1P: S`�-�3 <br /> Contact Person: ���,,,,� Applicant is: tra / Homeowner (Circle One) <br /> Email and/or Fax: 1�,��C,,,,o,�C��s�✓vz..� . {;� �---� <br /> PROPERTY OWNER�INFORMATION; <br /> Name: ��� /�/(�y� - <br /> Phone(day): t �-�4� y� /� j S'�� <br /> Address: (� � S�� (�.t. City' �,�,.. ZIP: ��� <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 8 peRnits: <br /> Minneheha Creek Wate�shed District(MCVW) <br /> ❑R�ro�f,asphalt �Repair [�JStorm Damage 18202 Minnetonka Blvd <br /> Daaphaven, MN 55391 <br /> Re-roof,cedar ❑Restorstion ❑Water Damage Phone: 952-471-0590 <br /> ❑Re-roof,vthe�(specity� ❑ Siding []Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.om <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ �� i 9 23 . <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by ths Building Departmont; <br /> • Certifies that the infermation supplied is true and correct to the best of his/her knowledge. The applicaM recognizes that they <br /> are solely responsible for submitting a cemplete applicstion being aware thet upon failure to do so, the staff has no altamative <br /> but to rejed it until it is complete; <br /> • Some or all of the ir�formation that you are asked to provide an this �pplication is classified by State law es ekher private or - <br /> confidential. Privete 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 gene�ally 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 reovrds and recards of other governmental agencies <br /> �e uired law. If ou refuse to su the information the a lication ma not be isaued. <br /> •--��---•,_ ••�___�..__. � �� n.,�... �l� �l� 11�1 <br />