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- . City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address. Permit number: Q.0 t(-- 0(`j it <br /> D,hr PO Box 66 - /^ ' <br /> Crystal Bay, MN 55323-0066 Date-received: / �{ `�# [( • <br /> (,a nF s, Street Address: Received by: �.(D <br /> �� i, rj!' o~ 2750 Kelley Parkway Plan review fee: <br /> i'kESH04" Orono, MN 55356 <br /> Total Fee: 1 <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 INFORMATION: _ <br /> Job Site Address: �3 S� C,OD(ve,7 ),-N oz_ L <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes t&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 I FORMATION: <br /> Name: 5i"«✓lq ` ro_pr-' [C'S <br /> State License # Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: ',, k )- (.,,llv--Lk'r t t 7 (office) (cell) <br /> Mailing Address: ISZo$0 E=,5\e- tvi ( ,/1 S[ City: p,,,,,,,_ L0(_P ZIP: X3 -7Z <br /> Contact Person: Lot, 4e>-re vl 0 4 n t Applicant is: Contracto / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: L0,---,. (-Ott e —e .. <br /> Phone (day): 6 c2 070•- -(22_8' <br /> Address: ..c1 Yc „)1-4i, -.,ti City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) -0 Remodel ❑ Fire Damage MCWD review& permits: <br /> ❑ Re roof, asphalt ❑ Repair Minnehaha Creek Watershed District(MCWD) <br /> p ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> E Re roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description:ge ic,/e t s,rC.plft(e /ey1C/C tt>of /('e//i. <br /> Estimated Construction Valuation of Project(excluding land) $ di <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 inform _tio to annually update our records and records of other governmental agencies <br /> required by law. If you refuse to s•.ply • e inf. mation,the application may not be issued. <br /> Applicant's Signature: e' .. Date: <br /> /J � _ i / <br /> Last Updated: 08-09-2011 <br />