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AUCs-1.6-21311 06:50 From: 6785736615 To:19522494616 Page:2/2 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address, Permit number. <br /> O�Q�O Cr Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> Gti 2750 Kelley Parkway Plan review fee: <br /> Orono,MN 55356 / �� <br /> �sEs Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.oronc.mn.us <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: 6 <br /> Job Site Address: Vll t' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? LJ Yes 4 No <br /> lryes,a special event permit is required with Police Department and City Council approve)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 I APPLICANT INFORMA ION: <br /> Name: SiMor C0V\_ 0C o "'I <br /> State License# j Expiration Date: J z <br /> D'� " a <br /> Lead Certification Number. Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: l Z • 8 E ` 7000 (office) (cell) <br /> Mailing Address: 12 66 13 v d City; �✓y,sv, / ZIP: 5 -2 <br /> Contact PersApplicant is: / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER ,��INFORMATION: <br /> �yYj `Y- <br /> Name: a1,a 145 <br /> Phone (day): A IZ- 32-7- 777 41 <br /> City: t�y�vLp ZIP: 5 j� <br /> Address: W65- I,v�. <br /> 356 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Protect: Any earth movement may require <br /> MCWD review&permits: <br /> []Door(s) ❑Remodel ❑Fire Damage Minnehaha Creek Watershed District(MCWD) <br /> 10 Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re roof, cedar ❑Restoration ❑ Deephaven,MN 55391Water Damage Phone: 952-471-0590 <br /> C]Re-roof,other(specify) ❑Siding ❑Other(specify) Fax: 952-471-0682 <br /> C]Window(s) www,minnehahacreek.org <br /> Overall Project Description: _TZc, ct 4C- rV0 <br /> Estimated Construction Valuation of Project(excluding land) $ "51e_ 3 Z <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Departrnont; <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 al lmative <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 applicafion may not be issued. <br /> Applicant's Signature: - <br /> Date: L16/zof/ <br />