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. �,w.r�` 3`�`'`'3 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation � ��� �S- <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number. G���01' D���3 <br /> Og,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 3 'ZD- 13 <br /> �� <br /> ������ '' �- Received by: S <br /> y � �, Street Address: <br /> �'.�, 'Q �� '���� �ti�' 2750 Kelley Parkway Plan review fee: (07 Sf Pd �l <br /> L9,kESK��'�' Orono, MN 55356 CL <br /> -- aoia-or�lq2- <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 /> JobSiteAddress: ',� �!�• �_� 'i��t� � \ � �,1�1�.�:_ � 1 �^>11(��� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a specia/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 su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �. -� �l 1 � ° �_.- <br /> State License# G .r--����,�(o Expiration Date: 3 31 / <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: Cl�� . �c'��� ��Z ��: (office) ����;�,_ j:.��( - �S��� (cell) <br /> Mailing Address: y`?� ` ��� i i � .�,� �} City: '� ���;�,� ZIP:� '��� <br /> Contact Person: T��K� �� �1�� Applicant is: (�ontractor �Homeowner (CircleOne) <br /> Email and/or Fax: j \ � � � l ,�_ ' -{_L; ' � <br /> � <br /> PROPERTY OWNER INFORMATION: <br /> Name: -��� � .�1( C.',, �.:� Il< �{ 1� � � ��r��{, <br /> Phone(day): <br /> Address: �y(v�^; ���i� l 1� 1 t l� City: l ��ill� ZIP: <br /> Email and/or Fax ` <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �{temodel ❑ Fire Damage MCWD review&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) www.minnehahacreek.ora <br /> Overall Project Description: � ' � � 1 <br /> Estimated Construction Valuation of Project(excluding land) $ `�r', C�',�.� <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'�enerally c nl�ot be given to the public but can be given to the subject of the <br /> data. Confidential data is informafion;whi�h gener Ily da n � given to either the public or the subject of the data. Our <br /> purpose and intended use of this infor�mat n is to annu�Ily, te our records and records of other governmental agencies <br /> re uired b law. If ou refuse to s4� 'I 'the formati n, h a � li fl ma not be issued. <br /> ApplicanYs Signature: ; �/ �! / Date: <br /> '� <br /> Last Updated: 08-09-2011 <br /> i� <br />