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NOV-10-2011 08:05 From: 6785736615 To:9522494616 Page:1�1 <br /> t � <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mar'ling Address: Permit number. c��//-�/ 7 <br /> O�,�,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: / - /D - <br /> � � a, Str�etAddress: <br /> Received by: <br /> ��' 2750 Kelley Parkway Plan review fee� <br /> �y��.xo¢O Orono, MN 55356 � <br /> Total Fee: �D 5. O� <br /> Main: 952-249�600 Fax; 952-Z49-4616 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 printJ <br /> GENERAL INFORMATION: �, <br /> Job Site Address: � dQ,r'vi� <br /> Will this be a Parade of Homes, Remodelers Showcas� Home or other Display Home? ❑Yes o <br /> lf yes,a special event permit is requtred with Police Department and City Council approval 60 days prior to the event. Shuttle bus s ice wi/l be <br /> requfred unless applicant demonstrates su�clent on-site park/ng is available. Non-permitted events w/ll nof be ellawed. <br /> CONTRACTOR/APPLICANT INFORMA710N: <br /> Name: �$ ,�vw�n �6�u�rL.�� <br /> State License# �q��,�_�( Expiration Date: y f�� <br /> Lead Ce�ification Number: Expiration Date: � <br /> (for work on homes that were constructed prfor to 1975 <br /> Phone: ���- '�oD� (office) (cell) <br /> Mailing Address: �` �;,P„� ��6 �.�,�_ City: ����� ZIP: 5�33 � <br /> Contact Person: ,�J .��,�� Applicant is: on �ct� / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: Gl�,r`rs G✓�'�L J'n 7 <br /> Phone (day): ��� _ 3g��.8��� ' <br /> Address: qg D C� �,�M ��. City: Ql�r� ZIP: S'"'s' 3,S'� <br /> Email and/ar Fax ' -' <br /> PROJECT tNFORMATION: <br /> Typ�of Project: Any earth movement may requlre <br /> ❑ Door(s) ❑ Remodel ❑ Fir Damage MCWD review 8 p�rmits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> [�e-roof,asphalt ❑Repair Storm Damage 18202 Minnetonka Blvd <br /> � ❑Watsr pamage Deephaven, MN 55391 <br /> ❑ Re-roofi, cedar estoration Phone� 952-471-0590 <br /> ❑ Re-roof, other(specity) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek ora <br /> Overall ProJect Description: <br /> Estimated Construction Valuation of P�oject(excluding land) $ / , 3 <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 applicent recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altsrna6ve <br /> but to reject it until it is camplete; <br /> • Some or all of the information th�t 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 giveh to the subject of the <br /> data. Confid�ntial daia is Information which generally cannot be given to either the public or the subjed of the data. Our <br /> purpose and intended use of this information is to annually update our records and records of other gov�rnmental agencies <br /> re uired b law. If ou refuse to s . I th�informati the a lication ma not be issued. <br /> Annliranf'eCinn�+��ro l _\ � 1� � r�,.i... f� / �U J� <br />