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' .1.4_, \--1 C.-./:..2., I) — it 6-C'' S'r:;-C <br /> . City of Orono <br /> . Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> --,, Mailing Address: Permit number: <br /> /g,(:).1 PO Box 66 <br /> 420 ON Crystal Bay, MN 55323-0066 Date received: <br /> A �. Street Address: <br /> Received by: <br /> �� o~J 2750 Kelley Parkway Plan review fee: <br /> �l9 g')/ Orono, MN 55356 <br /> kEsso � <br /> Total Fee: <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 INFORMATIO : <br /> Job Site Address: , 3 \ill (_LkY_('_,W CIC, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑YesJ 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 servi a will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP-P4CANT INFORMATIPN: <br /> Name: IV-\r-\k -V3 Xtt'.V \Lv`3 Inc• <br /> State License# UGtR Expiration Date: 3J 2( 1 2LA 2.. <br /> Lead Certification Number: 4 - U.-ET-ICJ-- Expiration Date: if Fi I Z(-`r---I <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 9.- -( j,; (office) (cell) <br /> Mailing Address: J-q.9(4 P( k, bion c) City:5f. --)0,1 j64JI(1, <br /> (.,(,11� L ZIP: < , <br /> Contact Person: `T) Ce( Lc3C'f Applicant is: C / Homeowner (Circle One) <br /> Email and/or Fax: ),-C70 -CI(y// <br /> PROPERTY OWNER INFORMATION: <br /> Name: -k:,\A‘c\.1. 1 y X 1'1\i.Ai G _\ <br /> Phone(day): (ft).- aolc--- lcs)« <br /> Address: 9:12-F3 \.1:.A\Ve C)G\L (._.'_\-X C\Q_ City:LSC0-,(, ZIP:C-634:3(<-) <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ D s ❑ Remodel MCWD review&permits: <br /> ( ) ❑F're Damage Minnehaha Creek Watershed District(MCWD) <br /> Re-roof,asphalt Repair Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar 111Restoration ElWater Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) <br /> www.minnehahacreek.org <br /> Overall Project Description: FCoc OC(- -•,- \t'--V C::{ <br /> Estimated Construction Valuation of Project(excluding land) $ (f1 LC C",`.c_<--; <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 su ly the in rmation,the application may not be issued. <br /> Applicant's Signature: zi .,„,, -- Date: \\ / /D0 I <br /> Last Updated: 08-09-2011 <br />