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„ 5�� � � �� � <br /> t �� 55 • � v1� � <br /> City of Orono � , /J ��3� .75 <br /> � Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: G���l—(`j/�g q <br /> �g,0,�� PO Box 66 <br /> �� ;k, •O\� Crystal Bay, MN 55323-0066 Date received: / -�/- / <br /> � �,r� I! <br /> I,�� � „ a,�� Street Address: Received by: <br /> 3 �_:� . $9 <br /> �' 2750 Kelle Parkwa <br /> �c�, ' ��. �� Y Y Plan review fee: <br /> 9kE'gH�¢� Orono, MN 55356 <br /> -_— Total Fee: <br /> a�l/-D / � <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) <br /> GEN RAL INFORMATION: <br /> Job iteAddress: � �q0 5�7SS�.yL �aJy� <br /> Will his be a Parade of Homes, Remodelers Showcase Hnrne or other Display Home? Yes No <br /> If es,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 su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATIQN: <br /> Nam�: M/} ��-�RSO� <br /> State License# (D7Oc� �_ Expiration Date: r�1,q�H Z012 <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: q S.?-9�S” t f()U �jCj �(office) (cell) <br /> Mailing Address �(p J QO 1�t,E,�'•,!G City:E� ��y ZIP: <br /> Contact Person: A S 0� �C d J(ZKouc.F�J Applicant is: ontrac / Homeowner (Circle One) <br /> Email and/or Fax: ,��}SOr.1K M•�PCT:23o�./ .�aM <br /> PROPERTY OWNE INFORAI�ATION: <br /> Name: �� �� 4���r��E� <br /> Phon�(day): q5?� �{7 5' YQC��- <br /> Addr�ss: 319v SvSS�-r �� City: rj2ptiob ZIP: 553��e <br /> Email and/or Fax <br /> PRO,UECT INFORMATION: <br /> Type f Project: Any earth movement may require <br /> ❑ Do�r(s) �Remodel ❑ Fire Damage MCWD review 8�permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt �, Ftepair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-�oof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-oof,other(specify) ❑Siding ❑ Other:(specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Overall Project Description: (,J r E Q/1 (�Q !�/✓� <br /> Estimpted Construction Valuation of Project(excluding land) $ /�j"b,oon <br /> APPL CANT 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 knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> I 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 /> Idata. 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 refuse to su I the information,the a lication ma not be issued. <br /> Applica�nt's Signature: Date: ��".���o���� <br /> Last Upd ted: 08-09-2011 <br />