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# r-. <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) . <br /> • Mailing Address_ Permit number: 0" ©l d-. <br /> E38 <br /> pate received: <br /> '�y"a 0.1 Pa Box Crystal Bay.MN 55323.0066 - <br /> Q Received ay: %c..I <br /> ":,V.,, Street Address: <br /> t6,,A. �'• 2750 Kelley Parkway Plan review�fee: <br /> ��' kr:tit <br /> iso Orono,MN 55356a , <br /> C Total Fee: <br /> Main: 952-249-4600 .. <br /> Fax: 852-240 4616 . .. <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: S Wt, <br /> *. \ <br /> Job Site Address: r No <br /> Will this be a Parade of Homes, Required emoddeith l fer ce Showcase <br /> eoe case Oily Home <br /> me o other Disdays prior m h event. Shuttle veA bus se• o be <br /> If yes,a spec/of event iapplicant unless demonstrates sufficient on-,gJte p6rking is aveAablQ. Non-permitted events will not be allowed- <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name; rset - - Expiration Date: 3 3! <br /> State License# �C.\30113-6Expiration Date: <br /> Lead Certification Number: _ __S,._1-,29-r 3 <br /> (for work on homes that were constructed prior to 1978 (cell) <br /> (oS 1- oZ • -4.0 (office) <br /> Phone: A City: � .s; C. ZiP: � Il'3 <br /> Mailing Address: IS . b .. 1 .• `• s• we <br /> Contact Person: _ Applicant is: ..on ra tVII / Homeowner (crmle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF RMA;ION:� - <br /> �� <br /> Name: <br /> Phone (day): l - City: ZIP: <br /> Address; _ <br /> Email and/or Fax <br /> PROJECT INFORMATION: Any earth movement may require <br /> Type of Project: MCWD review&permits: <br /> [7 Door(s) 0 RemodelFire Damage Minnehaha Creek Watershed District(MCWD) <br /> Storm Damage 18202 Minnetonka Blvd <br /> Re-roof,asphalt Repair Deephaven,MN 55391 <br /> 0 Re-roof,cedar 0 Restoration 0 Water Damage Phone: 952-471-0596 <br /> Fax: 952.471-0682 <br /> [ Re roof,otfier(specity) 0Siding (specify)Other: <br /> one ha ee c.S <br /> [I Window(s) <br /> CA Tin ., L-4--)S r(� ! S r <br /> Overall Project Description: ' <br /> Estimated Construction Valuation Project exciudin. land) $ • 5 nD — <br /> - <br /> APPLICANT ACKNOWLEDGEMENT: <br /> Agrees to provide all Information required or requested bythe Building Department;• edge. The applicant recognizes that they <br /> Certifies hat the information supplied is true and correctto <br /> being awarelslher that uponvfaiure to do so,the staff has no alternative <br /> are solely responsible for submitting a complete app <br /> but to reject it until it is complete; <br /> • Some or all of the einformation <br /> dat ais information thatare <br /> which generally asked to provide <br /> annot be given'totion is classified the public but can be State <br /> en to thesubjectof the <br /> data- . Private data is public or <br /> pure ed intConfidential data ise of failtionghe subject of the data. Our <br /> m <br /> " re,uired b law. if ou refuse.td-,.u.•,i _the information thee.•lir=tion ma not be Issued.. <br /> Applicant's Signature: Date: 3,46 <br />