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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) -Y,� <br /> Mailing Address: Permit number: Qf/s 3-6 <br /> y O�O <br /> Crystal Bay, MN 55323-0066 Date received: -� <br /> Street Address: Received by <br /> 2750 Kelley Parkway Planseviewfee: <br /> 4�a Orono, MN 55356 <br /> 5D <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- <br /> Job <br /> n <br /> Job Site Address: _ to <br /> Will this be a Parade of Homes, Remodelers Shovkase 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 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: <br /> State License# Chop ( a civ Expiration Date: <br /> Lead Certification Number: {�T , a-Sv3�— ( Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (o/o2— a 3 (office) (cell) <br /> Mailing Address: k City- SL-Cot.,is 10kr <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: 011 r-I(_ r l 16 U 2 a_, — <br /> Phone (day): �� c _-1 S -Re,(oq 4 r&jfi-t_ <br /> Address: 3 �p . �`�6- ie( � City: ZIP: Sj' <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 .Enepair -Ota•t ❑ 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.org <br /> Overall Project Description: et4pa.A Q-M- gp, "e�y of <br /> Estimated Construction Valuatiob of Projec (exc uding land) $ l �OO..W <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 supply the information,the application may not be issued. <br /> Applicant's Signature: Date: 71/�,13 <br /> Last Updated: 08-09-2011 -4 <br />