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� ` City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) C.� ��l I <br /> =__> Mailing Address: <br /> ��,�,� PO Box 66 Permit number: ��j- - �, <br /> Q, \ Q Crystal Bay, MN 55323-0066 Date received: 02 -a,D- 13 <br /> a l����'?�,� '. �, Street Address: Received by: �''✓� L..D <br /> �'�nt���y;;����,ti 2750 Kelley Parkway Plan review fee: <br /> `�kEsxo4'' 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: <br /> Job Site Address: � ` . ��. �� �_ <br /> Will this be a Parade of Homes, Remode ers Sh case 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 s rvic ill be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT�[INFORMATION: j � <br /> Name: �'•1...,� T7 ��,r.e 2�t..t i �-���'� L-�-C_ <br /> State License# • � � Expiration Date: , � <br /> Lead Certification Number: ' ,-� � . , �� �� `��� <br /> �s ��L�,�j���� -�G,� Expiration Date: ��,� � f �y j� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: ` � � � , '" ,�' " (office) ,. , ', Li `j (cell) <br /> Mailing Address: G�j�j � �' �;, ,� ,. City: (_t�� • �,,��5 ZIP: <br /> Contact Person: ��.� ,� Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: �c's �t1 �)f� i �+��1��1j'i.dt.��� (Cl32 �-!�; �' •:�l?jG� . �,�L�l�' <br /> PROPERTY OWNER INFORMATION: <br /> Name: [� � ,r� � ��,���..� �-� � <br /> Phone (day): - - . <br /> Address --f `s City: %� : ZIP: <br /> Email and/or Fax q : ., „ ' � <� �.t <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�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) �(�e'�y�Q��"�i�j Www.minnehah�creek.ora <br /> Overall Project Description: ` >Y/ , " c��e�r �' tn�.-- c�-!r� �'✓:;r - �fJla� <br /> Estimated Construction Val tion of Project(excluding land) $ Gjn,���, G?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 refuse to su I the information,the a 'on ma not be issued. <br /> ApplicanYs Signature: Date: d����,3 <br /> Last Updated: 08-09-2011 <br />