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! '-. <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Marling Address: Permit number: D1-7 O <br /> P------ <br /> 1.0:4-;:\ PO Box 66 /�� a - <br /> 0 „ Q Crystal Bay, MN 55323-0066 Date received: /` 1 <br /> Received by: - <br /> Street Address' <br /> ' 4;4 <br /> , . 2750 Kelley Parkway Plan review fee: <br /> < •0.0-k:,f.+` Orono,MN 55356 ' / <br /> ��_ � `'/ <br /> `�'rv•'° Total Fee: ` J <br /> Main: 952-249-4600 Fax: 952-249-4616 wwvi,cs.orono.ina s ; <br /> This application form must be completed In full and all required information must be submitted. /i/j(,' Q� <br /> Incomplete applications will be returned. (Please print) a) <br /> GENERAL.INFORMATION: <br /> Job Site Address: a:) R ..; L . , " <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? I 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 onsite parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 1%-L a_. - A .-vt" .erg <br /> State License# '$G13raqExpiration Date: — 3131 <br /> Lead Certification Number: (\31:VT- a--o:$3 -L Expiration Date: Lf/l'G <br /> (for work on homes that were constructed nrlor to 1978 (cell) <br /> Phone: (os 1- a[04-4.oS$- QC ,» (office) <br /> Mailing Address: • • ►. --*. " " t.. e.S4 City: .• ; t ZIP: SS 1 _ <br /> Contact Person: Applicant Is: • = / Homeowner (circle one) <br /> Email and/or Fax: _ -- <br /> PROPERTY OWNER INFORMATION: <br /> Name: .ir. ti, ICo-Liei-e-irv'' t„ <br /> Phone (day): — (` �2 • d Li _ <br /> Address: .1„ City: <br /> ZIP: <br /> Email and/or Fax — <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits: <br /> Ci Door(s) ❑ Remodel ❑Fire Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑Repair LI Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> 0 Re-roof,cedar ❑Restoration 0 Water Damage Phone: 952-471-0590 <br /> 0 Re-roof,other(specify) ❑ Siding 0 Other:(specify) Fax: 952471-0682 <br /> www.min nehahac,_reek.orq <br /> ❑Window(s) _ <br /> Overall Protect Descrn: to. "nc8 6.6v6. ---7:7-T-1,(1);A. t..', i f". e <br /> Estimated Construction Valuation of Project exicludin. land) $ 1. ': T 3.O! <br /> APPLICANT ACKNOWLEDGEMENT: <br /> — <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 supply the information the a••iloatlon ma not be issued. <br /> Aoolleant's Signature: OK 0 , • Date: c2� <br /> l9- <br />