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• City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, rewroof, etc.) <br /> Mailing Address: .. <br /> "� PO Box 66 Permit number: ". Z�'. '` L` 112 <br /> Q Q Crystal Bay, MN 55323-0066 Date received: !'--1: 1 q. <br /> �� ii*�.� Street Address: Received by I_ <br /> N. .- t 2750 Kelley Parkway <br /> g�v Pian review fee: <br /> a Orono,MN 55356 <br /> Total Fee:Fee: 7 (' <br /> Main: 952-2494600 Fax: 952-249-4616 y�y�v-4i.oronQ,Ynn-us . 31.,7 .; <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: 0( r 1 , \ <br /> Job Site Address: `1 1./V .0 C _i_,_k___ <br /> • <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? []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 on-site parking is available. Non permitted events will not be allowed, <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: `R°3-0Jo.\ 'B‘-k 'Qr\Atfe'N <br /> State License# -5C.-11018- Expiration Date: <br /> Lead Certification Number: — � � <br /> AI- a`4'-c?S 3 -l Expiration Date: �f <br /> (tor work on homes that were constructed prior to 1978 <br /> Phone: 1- oQ(p — {.Q l- %ma ,, (office) <br /> Mailing Address: 9 a• Co, 1 •* WeCity: • (cell) <br /> v,1 t, -ZIP: 5'51 <br /> Contact Person: <br /> Email and/or Fax: ' Applicant is: ontra • / Homeowner (Circle One) <br /> PROPERTY OWNER INFORMATION: �l <br /> Name: v,� Hcx(l; `, <br /> Phone (day): 40 I <br /> Address: <br /> Email and/or Fax - City: ZIP: <br /> PROJECT INFORMATION: <br /> Type of Project: <br /> Any earth movement may require <br /> d Door(s) ❑Remodel MCWC review& <br /> 1a Fire Damage permits: <br /> ❑ Re-roof,asphalt Repair Minnehaha Creek Watershed District(MCWD) <br /> P �]Storm Damage j 18202 Minnetonka,Blvd <br /> Q Re-roof,cedar I Li Restoration [J Water Damage Deephaven, MN 55391 <br /> El Re-roof,other(specify) 0 Siding ( Ry) Phone: 952-471-0590 <br /> ❑Other.(spectfy) Fax: 952-471-0682 <br /> 1Mndow(s) www.minraehehacreek.ora <br /> Overall Project Description: Lurk. ce C._il �F <br /> Estimated Construction Valuation of Project excludingland) c SS S mi <br /> I <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 /> . re.wired b law. If ou refuse to su..l the information the application ma not be issued. <br /> Aooiicant's Signature/ r,/r ! G-1-------- <br /> Date: / l(1fr/(7 <br />