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City of Orono <br /> F - Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: .4 /(- h <br /> j� 0PO Box 66 � <br /> 0 • O <br /> Crystal Bay, MN 55323-0066 Date received: /(_3 —/ I <br /> A I i\ a, Street Address: Received by: , <br /> tin I O i, �, o~ 2750 Kelley Parkway Plan review fee: <br /> ty Orono, MN 55356 <br /> Total Fee: .-7//J 7 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us /t`+O <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) /j1/;6 <br /> GENERAL INFORMATION: Com(✓ 22� <br /> Job Site Address: -;/6"o� e��i/j% 4)4Jl�/7© 1� �� C/1 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Al-No <br /> 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: . id'e2,. Dpi <br /> State License # Z>z.,,. j� Expiration Date: 3j/ 7,Z. <br /> Lead Certification Number: ,f//1- jp217,79 Expiration Date: /'• /-4_� <br /> (for work on homes that were constructed prior to 1978 / <br /> Phone: 3 —5/7, ..g 79 (office) (cell) <br /> Mailing Address: — , <br /> Contact Person: 6 Applicant is: Contrgctor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: / <br /> Name: 5,�=,/'/_ �9 3 'h/// <br /> Phone (day): / <br /> Address: -G, 7 ��/ �'--� ALJ / 4.- Cit J4/�/6/ 7ZIP:�' � _97 <br /> Email and/or Fax <br /> 6 ' "'a/,iL>P s /7/c,‘,5-e_-_-,--,// 7/ (4-24., ----�© ' 56 - /f. ,.. .- .7-- ---- <br /> PROJECT INFORMATION: 2. GATstiry.�5• y-a,*3,��,q � <br /> � yy��� ��„� /�� <br /> Type of Project: <br /> Any earth movemen may require <br /> CIDoor(s) CIRemodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> U Re-roof, asphalt ❑ Repair ❑ Storm Damige 18202 Minnetonka Blvd <br /> ® Re-roof, cedar ❑ Restoration CIWater Damage Deephaven, MN 55391 <br /> GIRe roof, other(specify) Phone: 952-471-0590 <br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ b'/ e9D <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by thQ 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 /> c7 <br /> Applicant's Signature: / i - //` <br /> ��,v��2-rte �.+� _ 'iceDate: //`A-- <br /> Last Updated: 08-09-2011 <br />