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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 /> �.¢,O,�j:� PO Bax 66
<br /> %/ , \\ Crystal Bay, MN 55323-0066 Date received:
<br /> !
<br /> �r` i'
<br /> � Received by:
<br /> ,� ,��`�,�,�,�:� �,Ij Street Address:
<br /> ��',�, �� >�,� Gti�' 2750 Kelley Parkway Plan reviewfee:
<br /> �lyk���.�,�/ Orono, MN 55356
<br /> �Esao��
<br /> Total Fee:
<br /> Main: 952-249-46d0 Fax: 952-249-4616 wrrrw.ci.ar�no.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: �$��L. � �4.�. �"'��A a�10 Y�--N �"'3(�p�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home? ❑Yes ❑ No
<br /> lf yes, a special event permif is required with Polrce Department and City Counci/approval 60 days prior to the event. Shuttle bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking rs avai/able. Non-permitted events will not be af/owed.
<br /> CONTRACTOR/APPLICANT NFORMATION:
<br /> Name: ,,,,y�� �.,
<br /> State License# �+�(g�yq�°�°�+�^— �Expiration Qate: '�
<br /> Lead Certification Number: �f��'"� ����p�� Expiration Date: �
<br /> (for work on homes that were canstructed prior to 9978
<br /> Phone: '�,., Z,,,Ld .. (otfce) �c,.dE�N (.rz�—�,---Z�,,,1 —• � (celq
<br /> Mailing Address: tv► S �l/V,J c�' Cit : � �} C� ZIP; �
<br /> Contact Person: � Applicant is: ontracto Homeowner �c�r�ie o�}
<br /> Email and/or Fax: t^� �y�,e S'b�,v,t,� (�e,a,��y,�r��• �1 s„�,
<br /> PROPERTY OWNE INFORMATION:
<br /> Name: ,Lt,�
<br /> Phone (day): �_ �"7 j .. S
<br /> Address: � ��-� �NI..,�,�,�v �! City: j�4r���,� ZIP: � �
<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 8�permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> e-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: 952-471-0662
<br /> ❑Window(s) www minnehahacreek.orq
<br /> Overall Project Description: � � �
<br /> Estimated Construction Valuation of Project(ex uding land) $ �"�, � �
<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 informatio which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use of this i mation 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 lication ma not be issued.
<br /> ApplicanYs Signature: Date: 'S �"7
<br /> Last Updated: OS-09-2011
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