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City of Orono <br /> Building Permit Ap�lication for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> �O Mailing Address_ <br /> �' �' PO Box 66 Permit number: � Q -'�0 S� <br /> � �� Q Crystal 8ay, MN 55323-0066 Date reoeived: �o-vZ -/ <br /> � ,��,:'� � Str�etAdd�ss: Received by: <br /> �, � <br /> E' 4�0'` 275U:Kelley Parkway Plan r+eview fee: <br /> �sHo Orono, MN 55356 <br /> ` Main: 952-249-4600 Fax: 952-249-4616 www.Gi orono mn us Total Fee: d( L I, `� <br /> / / <br /> This application form must be c4mpleted in full and af�required inforrnation must be submitted. <br /> lncomplete applications wil! be retumed. (Please prrnt) <br /> GENERAL lNFORMATION• <br /> Job Slte Address: 3� � �,�{ � '� �� <br /> Wil!this be a Parade of H�mes, Remodeler�,Showcase Home or other Display Home? Yes <br /> /1 yea,a Specra!event pe�mit ia required wrfh Volice Ogpartment and Cify Council a � N� <br /> required un/ess spplicant demonstrates sufficient on-site arkin pProva!60 days p�or to the event. ShuKle bus servrce wil!be <br /> p g is available. Non-permi[ted events wAl nof be adowed. <br /> CONTRACTOR 1 APPLICANT INFORMATI�N: <br /> Name: ����� <br /> __�wa.\ 'A <br /> State License# �C„�309$3 �cpiration Date: <br /> lead Certification Number. ��31 <br /> �"' a�Q7$3 - 1 Expiration Date: y��� <br /> (for worlr orr homes lhai were constructed nrro�tp 1978 -` <br /> Phone: (e5�_ a�-�a�� (office) — <br /> Mailing Address: � a� , � ,� „ e� C� {cefl) <br /> Contact Person: tY��C.v;l e. ZIP: 55113 <br /> Ernail and/or Fax: Applicant is: ontractor / Homtowner (ci�e�a,e) <br /> PROPERTY OVyNER INFORMATION: <br /> Name: �_�t1..� � !'\G'���_ <br /> Phone (day): -G9Y <br /> Address_ � �.,� <br /> Email and/or Fax C��� ZIP: <br /> PROJECT INFORMATION: <br /> Type af Project: <br /> My earth movoment may requine <br /> ❑ Door(s) ❑Remodel [J Fire Damage M���view 8 permits: <br /> ❑ R�roof,asphaft ❑ Re air Minnehaha Creek Watershed District{MCWD) <br /> P [] Storm Damage 18202 Minnetonka Bfvd <br /> ❑ Re-roof,cetlar ❑Restoration �Water Damage Deephaven, MfV 55391 <br /> ❑Re-roof,other(specify) ❑Sidin Phone: 952-471-0590 <br /> 9 '�„p p� ther: (s eci ) <br /> � ���«� �� Fax: 952-471-fl682 <br /> �Window(s)��' � www minnehahacreek orp <br /> Overall P�oject Description� � � <br /> Estimated Canstruction Valuation of Project (excluding fand} $ <br /> � <br /> APPLICANT ACKNOWLEDGEMENT; <br /> • Agrees to provide all inflormatlon required or re'quested 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 responsibte for submitting a completie application being awar�e that upon failure to do so, the staff has no alternative <br /> but to reject it uniil it is complete; , <br /> • Some or a!I af the inforrnativn that you are asked to provide on this application is classified by State law as either private or <br /> confide�tial. Private data is informa#ion 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 eiiher the public or ihe subject of the data. Our <br /> Purpose and intended use of this information is to annually update our records and recorrls of other govemmental agenc�es <br /> re uired b law. ff ou refuse fo s I the information,the a fication ma not be issued. <br /> Aoo(icant's sianature: p� �� �� <br /> Date: a�� <br /> Z 'd 06i9�L9TS9 3�IA213S lIW?J�d Q '8 S �1 0� ��i ETOZ L� un� <br />