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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: d 0/ / -0 / e/3 67
<br /> 011 Cr Bax 66
<br /> �� Crystal Bay, MN 55323-0066 Date received: / / "�' —1/;
<br /> a i
<br /> Ov
<br /> y: . s, Street Address: Received by:
<br /> 1, l f,�(l o~ 2750 Kelley Parkway Plan review fee:
<br /> 9g�sHo4w Orono, MN 55356
<br /> Total Fee: �!TMJ,. 50
<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: -2c..----v. LAJokes0 ff-rc.1/4._ 0.40
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes NNo
<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: 604-v 4 `-(C-vc 0"/( ice`
<br /> State License# , 'C 200-1'7cto Expiration Date: 3' 'Z,ci3
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (office) -7G3`t' d°t37 (cell)
<br /> Mailing Address: ei S3w (d A",,,, 641_4, City: (,v, 7ws%. ii,yvZIPS3-n y
<br /> Contact Person: l,n•kCr9.2,144A_. Applicant is: of-13ac or / Homeowner (Circle One)
<br /> Email and/or Fax: 1--(,,,,,e ectik-er coeisie,ef'ovi.,•
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: L)J 1-i7 c - 6- JnfIN(1-)>' Gi-i 6
<br /> Phone (day): r-.,--- 34S —O'1 g`'( Co U5 (ovsrA.psaN _Co% - - nn,4N 62)--
<br /> Address: --Z-e,- LA/c.)_)0 ft AR City:a0,t/t vA -)4- ZIP: s-5-3c?(
<br /> Email and/or Fax 5 v Q u..o..,0t-iv-,-1,�,CM
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> El Door(s) 0 Remodel 0 Fire Damage MCWD review&permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> •
<br /> ❑ Re-roof, cedar 4St Restoration 0 Water Damage Deephaven, MN 55391
<br /> Re-roof, other(specify) 0 SidingPhone:: 5295471- 6820
<br /> 0Other: (specify) Fax: 952-471-0682
<br /> g*p,( � 0 Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: 5netp /0,,F72),o .‘,.. ,pc,/V4, 2vgdfJL 4,.,.c f &Ocec, - t -I.-
<br /> Estimated Construction Valuation of Project(excluding land) $ ZSTv�s.,
<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.tion is to annually update our records and records of other governmental agencies
<br /> required by law. If you refuse/ -Ilipolyt I- information,the application may not be issued.
<br /> Applicant's Signature: ✓--
<br /> Date: U(iY/((
<br /> Last Updated: 08-09-2011
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