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MA1 7-2014 10:08 FROM:TREBILFOUNDATION SYS 3205938720 TO:19522494616 P.2 <br /> I <br /> j City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Melling Address. Permit number <br /> o?o <br /> 0�0 PO Box <br /> Crystal Bay, MN 55323-WW Date received: <br /> Street Address: Received by, <br /> 2760 Kelley Parkway Plan review fee: <br /> Orono,MN 55356 � LL <br /> Total Fee; �O•�.7 <br /> Main: 952-2494600 Fax: 952.249.4616 www.ci.orono.tnr.us I - f <br /> "lfffnn <br /> This application form must be completed in full and all required information must bebmitt <br /> GENERA!.INFORMATION- <br /> Incomplete applications will be retumed. (Please print) <br /> �� / <br /> Job Site Address: � <br /> Wilt this be a Parade.of Homes,Remodelers Showcase Home Home or other Display Home? Yes No <br /> If yes,a special event permit is required w$h Poke Depotrnant and City Cbmwo approval 60 days pdarto die event, Shuftb bus servkm will be <br /> required uniass applicant demonstrates suM*nt on-site parkins is ave®able. Non-permtded events wIB not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION! <br /> Name: i <br /> State License 0 Expiration Date: � <br /> Lead Certification Number. — Expiration Date: <br /> (for work on homes that were constrtic[eC1 prior to 1878 <br /> Phone: aRQ (office) (call) <br /> Mailing Address: City: ,Z1P: <br /> Contact Person: p Applicant is: Contractor' / Homeowner (cadnorwl <br /> Entail and/or Fax. / <br /> PROPERTY OWNER NFORMATION• <br /> Name: Nru Y Al r-,0-4n(!G <br /> Phone(day): <br /> Address: 'Z4 City: Q✓47-l"0 ZIP: 11551:5 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project Any earth movement may require <br /> 0 Doors) 0 Remodel p Fire Damage MCWD review&permits; <br /> Minnehahe Creek Watershed District(MCWD) <br /> 0 Re-roof,asphalt epair Q Storm Damage 1842 Minnetonka Blvd <br /> ❑Re-roof,cedar Restoration Q Water Damage Deephaven,MN 55381 <br /> Phone: 952-471-0590 <br /> 0 Re-roof,oth4r ienectfy) ❑Siding ❑Other: (spehdfy) Fax: 952-471.0882 <br /> [) <br /> Window(s) www,minnehaharxeek a <br /> Overall Project Description; <br /> Estimated Construction Valuation of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied Is tree and correct to the best of his/her knowledge. The applicant recognizes that they <br /> aro 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 ail of the information that you are asked to provide on this application is dassififed by State law as e'Ittw private or. <br /> confidential. Private data is information which generally cannot W givers to the public but can be given to the subject of the <br /> data. Confidential date i8 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 /> uired law, If you refuse to supj2ly the information the application mq not be issued. <br /> Applicant's Signature: Date: <br /> Last updated: 08.092011 <br />