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City of Orono <br /> !� Building Permit Application for Maintenance I Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: <br /> 0J PO Box 66 Permit number: Q/ <br /> Q © Crystal Bay, MN 55323-0066 Date received: <br /> a 9 Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: <br /> ts-kks o4� Orono, MN 55356 <br /> : <br /> Main: 952-249-4600 Fax. 952-249-4616 www.ci.orono.mn.us Total Fee: <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: RR / <br /> Job Site Address: Z S ,¢ <br /> 4 5— TNoRov,� pz---b L.ti 40NO N(Al 5'5-3 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,2�rNo <br /> If yes, a special event permit 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 sufficient on-site parking is available. Non-permitted even will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Z e N,DoN /moo 'r' O EA-t a AFL t2 jr- T cE?v yb:�^ <br /> State License # 2O& Z& S $$' Expir tion Date: e <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: Z6p-�61� (office) (cell) <br /> Mailing Address: 3*6-reV�n-PE' o— !`Aw City '& 6A.4,6 ZIP: 3'5'_T6 <br /> Contact Person: /f,0 7r erN t.-, Applicant is: t / Homeowner (Circle One) <br /> sr� <br /> Email and/or Fax: r� /a,n ,., ma .wc <br /> .na" o �►�— �ZEat ..*mow. - <br /> fir.,Q _ <br /> �_.._ � _ <br /> PROPERTY OWNER INFORMATION: <br /> Name: S4E-VOF 5r46E7—.4 C_ <br /> Phone(day): �S'Z, ey 3 <br /> Address: ZS�S' 7'hRo�to 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&permits: <br /> ❑ Re-roof, asphalt Minnehaha Creek Watershed District(MCWD) <br /> p ED El Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re roof, other(specify) ❑ Siding KOther: (specify) Far.: 952-471-0682 <br /> ❑Window(s) �j-q-S ��K � ,� www.minnehahacreek.om <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) <br /> APPLICANT ACKNOWLEDOEME_NT: <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 /> 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 annually update our records and records of other governmental agencies <br /> i[ required by law. If you refuse to su i the information,the application may not be issued. <br /> Appiicant's Signature: Date: o Z <br /> Last Updated: OS-09-2011 <br />