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SE'P--151---2011 11 :35 AM WALKER, ROOFING 6512510916 P. 01 <br /> City of Orono <br /> Building Permit Application for Maintenance I Renovation <br /> (windows, doors, siding, re-roof, etc,) <br /> Melling Address: Permit <br /> c7(/-0/� <br /> Crystal Bay, MN 55323-0068 Date received: /j���/ <br /> Street Address; Received by: <br /> 2750 Kelley Parkway Plan review fee:Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 962-249-4616 www.ci.orono,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: , t G7tf - e <br /> Job Site Address: "1 I 5 W a1T 7 t4N �. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o , j <br /> /fines, a special event permit Is required with Police Department and City Council approval 60 days prior to the event, Shuttle bus service III be <br /> required unless applicant demonstrates sufficient on-site parking Is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: )4,.1b4-1.--fr-Lit 124 o)C <br /> State License# g4,1,9 Expiration Date: '5/31 / l - <br /> Lead Certification Number: NAT- Jo__ Expiration Date: g <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 01-25(-04k10 (office) (cell) <br /> Mailing Address: 24141 cAPI° fLO City; PA- .JL ZIP: 55-( c( <br /> Contact Person: ,,q,opy Applicant is: ra Or Homeowner (clrcl.one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION; <br /> Name: , 1! I#4• •• Pl. <br /> Phone (day): 501- f io - <br /> Address: 327 INI,uR . CA-9-p,1nl4r- ,q-4C City: ,j144 ZIP: 21314 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits: <br /> ❑ Door(s) 17 Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) <br /> ;IKRe-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> El Re-roof, cedar ElRestoration IDWater Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Fax: 962-471-0682 <br /> ❑Window(s) www,minnehahacreek,arc <br /> Overall Project Description: -194 r b r rt-f 1011 0AI.. <br /> Estimated Construction Valuation of Project(excluding land) $ MS. $5 <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 lawif you refuse to SU {y the information,the application may not be issued, <br /> Applicant's Signature: Date: liq ) ( <br /> Last Updated; 08-09-2011 (-Al t I_► IT U - A ,a 191 iCA.4 <br />