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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> O MaIIing Address: <br /> PO Box 66 Permit number: ioll— aL,3 <br /> 0 Crystal Bay,MN 55323-0066 Date received: <br /> Received by. <br /> a '✓ a I Street Address: <br /> 2750 Kelley Parkway Y Y Plan review fee: <br /> 9xEsfiog� Orono,MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: Q/ /o/Z// <br /> I( <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: <br /> Job Site Address: 525 Will w ;1e so, <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? Yes No <br /> H 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-perdtted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 112ft Home 5 <br /> State License# 1 Expiration Date: <br /> Lead Certification Number: NA1- I05159- I Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: CV- (office) 614- ( -64!P (cell) <br /> Mailing Address: 3 1 k I City: ZIP: S <br /> Contact Person: Applicant is: Contractor / omeowner (cards on.) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMA�1TION(- <br /> Name: m6f�k Moor►IDU.'S�. <br /> Phone(day): 7,0_ 3 <br /> Address: g05' ,140 City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) ®Remodel ❑Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Fax: 952-471-0682 <br /> Window s) www.minnehahacreek.ora <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ <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 supply the infory0ation,the application may not be issued. <br /> Applicants Signature: Date: /6 <br /> Last Updated: 08-09-2011 <br />