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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address_ <br /> 0O7. 4 PO Box 66 Permit number:Q Crystal Bay, MN 55323-0066 Date received: <br /> 14ii, ,y� Ar Street Address: Received by: <br /> *,,t 2,14 • o' <br /> tiltit2750 Kelley Parkway <br /> ti044. Orono, MN 55356 Plan review fee: <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: , 1 1OS 1W �� ` <br /> Job Site Address: y --?NA <br /> Will this be a Parade of Homes, Remadeiers 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: 'ntwo l A trSe� <br /> State License# —6C-1-009 8-3 <br /> Expiration Date: 3/31 <br /> Lead Certification Number: <br /> i\ ,A'T- al.a' 3 — 1 Expi ation Date: 4/16 <br /> (for work on homes that were constricted prior to 1978 <br /> Phone: (05 i— tD4_4}-}-1, (office) <br /> Mailing Address: ( li) <br /> 19 a o co. ►id c. Wes+ City:?. tV;ut ZIP: Ss 113 <br /> Contact Person: <br /> Applicant <br /> Email and/or Fax: pp is: [contractor / Homeowner (circle orlo <br /> PROPERTY OWNER INFORMATION: <br /> Name: AtI` Y CSA_\ <br /> Phone (day): ka 12" X91 -- ( 21.10 <br /> Address: t S..-� <br /> Email and/or Fax City: ZIP: <br /> PROJECT INFORMATION: <br /> Type of Project: <br /> ❑ Door(s) <br /> Any earth movement may require <br /> ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof, asphalt Minnehaha Creek Watershed District(MCWD) <br /> ❑Repair 0 Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration 0 Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Re-roof,other(specKy) 0 Siding ❑ Other. (specify) <br /> ❑Window(s) www.minnehahacreek.oro <br /> Overall Project Description: A0.46, Z1 o 5CA.S :v-1._ <br /> ` <br /> Estimated Construction Valuatio of Project (excluding land) $ �-0 C ' �� <br /> 0 <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 applica t recognizes that t ey <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the taff has no alternatve <br /> but to reject it until it is complete; <br /> i <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 b law. If you refuse to supply the information, the application may not be issued. <br /> goolicant's Sianature: Q 07eN.0 Date: Sbe c i Z <br /> 2 'd 06I917L9TS9 33IAN3S .INN d a B S I'1 SS =ZT 2102 SO Dell <br /> I <br />