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I <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: t' l Z <br /> Cr Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: p <br /> 2750 Kelley Parkway Plan review fee: ( 7 <br /> LyxEsso4�v Orono, MN 55356 a / SO <br /> - Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us C5C,fwd (Q(CI Ulf; -7 -ZOl <br /> This application form must be completed in full and all required information must be submitted. 2p1 Z _0W I(o <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 315 -ronKQwa, 600-A— 0V0-po M SS 35'(p <br /> Will this be a Parade of Homes, Remodellers Showcase Home or other Display Home? ❑ Yes 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 seice 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: j ilb S e_ <br /> State License# 1 I S(o Expiration Date: l <br /> Lead Certification Number: N pr- - )0(0 189 - 1 Expiration Date: ! a0/ <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: I5A _ 4-TS_p—_-.49 (office) (cell) <br /> Mailing Address: (op) (2.0 City: N mhe{cm{COk ZIP: SS' 5oS <br /> Contact Person: JaS Qy Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ���o,.Y1Q5, Com, QQ� -7 <br /> PROPERTY OWNER INFORMATION: f� �(� I �, Z� / <br /> Name: rrox4*- n-ole_ir) ,t1o_n kandu a 1w-gi 1hmin'•coo <br /> Phone (day): 95A- IP7 3 - tS(O-1 3 <br /> Address: its T'a,�12o�City: 0r-Uy�o ZIP:Qrarcti ZIP: �S351p <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 /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Overall Project Description <br /> Estimated Construction Valuation of Project(excluding land) $ -7 S 000 <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 /> required by law. If you refuse to sV41y the information, application may not be issued. <br /> Applicant's Signature: Date: ���- / "& <br /> Last Updated: 08-09-2011 <br />