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' RECEIVED <br /> City of Orono <br /> JUN 2b(hiiling Permit Application for Mainte nce / Renovation <br /> CITY OF ORONO (windows, doors, siding, re-root-etc.) <br /> Mailing Address: 01 —004p0 <br /> O PO Box 66 ermlt numbe . <br /> 0 Crystal Bay, MN 55323-0066 Da a received: -� <br /> Street AddJKey <br /> Re Ned by: <br /> 2750 Parkway Plan review fee: <br /> 04Orono55356Zotal Fee: <br /> Main: 952-249-4600 Fax: 952- 4616 www.ci.orono.mn.us <br /> This application form must be co p ted in full and all required i ormation must be submitted. <br /> Incomplete a plica ' ns will be returned. Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 345 T'vn O_ R0. or-&Iqd MN S'`335-Zo <br /> Will this be a Parade of Homes, Remodel Showcase Home or other Display Home? ❑ Yes No <br /> /f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se ice will be <br /> required unless applicant demonstrate sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR ATI N: <br /> Name: Jernserl Z:I,e , <br /> State License# I I d5e.0 I Expiration Date: 3-61 -/3 <br /> Lead Certification Number: pA-7- - !D 6 1" -! Expiration Date: 3-j4 - a0 <br /> (for work on homes that were constructed#nor to 1978 <br /> Phone: 45211 - V-y S-dg Sr (office) (cell) <br /> Mailing Address: 1pol [aAWS&I A / S City: ZIP: 55 30t, <br /> Contact Person: Jo_md "-L „ Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: IN14P tejUkil komeA- Ce"I <br /> PROPERTY OWNER INFORMATION: <br /> Name: Ma_r4o_ YYWA..m'dia-f) <br /> Phone (day): q 5-A - 473- 5(0-7 3 <br /> Address: 3 IS 7)MNAA4� Aoc&- City: OrOrt 6 ZIP: 5S 35Z4 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) 3, ./Remodel ElFire Damage MCWD review&permits: <br /> IX 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.oro <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ /e 5, poo <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 in mation is to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to Uoply the informationKe a cation may not be issued. <br /> Applicant's Signature: Date: `-,?L 'Z <br /> Last Updated: 08-09-2011 <br />