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. <br /> � City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> _ — Mailing Address: Permit number: <br /> �.�j,�,�:�.\ PO Box 66 <br /> 'O O� Crystal Bay, MN 55323-0066 Date received: <br /> � � i� Received b <br /> �,� �t�IR,�-_, �,!� Street Address: Y� <br /> \�`�, ���'�;�9�,�1_ �tii�' 2750 Kelley Parkway Plan review fee: <br /> \lyX sfHo'g,�v% Orono, MN 55356 <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 INFORMATION: 2 - � " / <br /> JobSiteAddress: �;��� C�{V�-v'1GL( � nrD�O t� � ���✓�ti° <br /> Will this be a Parade of Homes, Remodelers Showca e Home or other Display Home? ❑Yes ❑ No <br /> If yes,a special event permit is required with Police Department and City Counci/approva160 days prior to the event. Shuttle bus service will be <br /> required unless app/icant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ���5"U /Z�5�� <br /> CONTRACTOR/APPLICANT INFORMATION: � C��Z� E/K lel✓�P�''MN <br /> Name: �j I-� �U1"1,�S l-�-L /� Q.it .�u> SS 33D <br /> State License# �j,�3 j� 7�5(p Expiration Date: 3j Z <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: '7(d 3 .- �f`];Z - �/'� � (office) _ (cell) <br /> Mailing Address: P� ���c j/c� City: • '��.� ZIP: ,-rr� ��g <br /> Contact Person: fp� µ�,���— Applicant is: ontrac / Homeowner (CircleOne) <br /> Email and/or Fax: ~7 j� � .- �;-7•Z. -4.LL�, <br /> PROPERTY OWNER INFORMATION: <br /> Name: �TYc'v�t h'c'Z�-WL�t� _ <br /> Phone(day): �S� . �,y� - 3�> �D <br /> Address: ��UC� ��/�t dt' /Ei� c�ty: pro,��, ZIP: `�535'ro <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 /> �2e-roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Phone: 952-471-0590 <br /> ❑ Re-roof,other(specify) ❑ Siding ❑Other: (specify) Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> ❑Window(s) <br /> Overall Project Description: �{�o;�p y� y �.��(��-Y ��� <br /> Estimated Construction Valuation of Project(excluding land) $ ��t� <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 uired b law. If ou ref se to su I the information,the a lication ma not be issued. <br /> ApplicanYs Signatufe: -� �y' �� Date: ��i/�/� <br /> Last Updated: 08-092(lir� <br />