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City of Orono �- '� <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) 'l <br /> Mailing Address: Permit number: <br /> 'Qv O•�0 PO Box 66 <br /> O <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a Street Address: Received by: <br /> �� o~ 2750 Kelley Parkway Plan review fee: <br /> L�kESAO, Orono, MN 55356 <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 /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: 4711C) _TbrtKa, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes X No <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 events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Home.0 C'I 1_c,:;.-en IL LC <br /> State License # (�C 3,(C �2—r Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: ( -5 I- `i k3 19 7 (office) 7 C 9 R 3 -)1 7 (cell) <br /> Mailing Address: Ali(5 'cf Sc• City: z ZIP: 3 sc <br /> iL <br /> Contact Person: Le.uiei,\ Applicant is'- on racto / Homeowner (Circle One) <br /> Email and/or Fax: h' cmy��6;e 14urzn r_—_ {�i �rnu1c l cc r" <br /> PROPERTY OWNER INFORMATION: <br /> Name: [L ;c KPhone (day): <br /> Address: �I 7�C l—c nl�� V.zi~; 4_e n_Q_ City: cr) he ZIP: SS 3 6`� <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 <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> El Re-roof, other(specify) Phone: 952-471-0590 <br /> (sp y) ❑ Siding 4c Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) _•{-• t eir_s www.minnehahacreek.org <br /> •c <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project (excluding land) $ f ? 0,0 O o <br /> APPLICANT 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 /> 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 /> re uired hv law. If ou refuse to su I the information, the application may not be issued. <br /> Applicant's Signature: L--L-L�, Date: <br /> Last Updated: 08-09-2011 <br />