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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permitnumber; /�f?-�� , 'a <br /> ce%,0 PO Box 66 . <br /> Ok. O <br /> Crystal Bay, MN 55323-0066 ,SDate�recei, .• (��� '" . <br /> :Received b <br /> a 1I �i'- a, Street Address: Y <br /> �,^� ,- cti 2750 Kelley Parkway Plan.reviewfee: <br /> gkESHog� Orono, MN 55356 <br /> Total Fee ,Avor <br /> Main: 952-249-4600 Fax: 952-249-4616 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: <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers 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 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: ;/ G- 1/ .r›rrSj UGfiC").cJ <br /> State License # xe- . Expiration Date: �3� 7`� <br /> j J� <br /> Lead Certification Number: / 0,X 9_/ Expiration Date: /7/2,p, A <br /> (for work on homes that were constructed prior to 1978 l <br /> Phone: <br /> / /07 --/ 7 f �� (offce) i�� -" (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: 4-;4.__/A.- 6,,,,Z /��i Applicant is: ontrac o / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Ji�/ 4.-%t/i,9 r./ /.Y/ <br /> Phone(day): ;U — zz.,,y cs/ G 12...-9/d-357`5' 7 <br /> Address: Cit%gi p/ ,,9 ZiIP: .5 :-,-7:. <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) E Remodel E Fire Damage MCWD review&permits: <br /> ❑ Re roof, asphalt Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar E Restoration E Water Dam ge Deephaven, MN 55391 <br /> ❑ Re-roof, other(specify) ❑ SidingPhone:: 5295471-06820 <br /> EI (spe ify) Fax: 952-471-0682 <br /> X(Window(s) www.minnehahacreek.orq <br /> Overall Project Description: 7 --41.7.7e-x---- -,,,�� `�,¢ c ,a'o S <br /> Estimated Construction Valuation of/Project (excluding land) /$ /���d - <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 uppr he information,the application may not be issued. <br /> Applicant's Signature: �� � . ----2- Date: /-26-://(:::-_ /e <br /> Last Updated: 08-09-2011 <br />