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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: d/ —,l�D/p�D <br /> �� 0 '�� PO Box 66 <br /> ''Q� ���� Crystal Bay, MN 55323-0066 Date received: �� �( <br /> ;i �� <br /> �1 ,�� Street Address: Received by: <br /> �'� 1� ��- .. s. , <br /> � �' `��".�. �'`� 2750 Kelle Parkwa <br /> Y Y Plan review fee: <br /> �lRk� Y���g�G~/� Orono, MN 55356 � <br /> ,__ESHo:::- ��5, OS <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: '1� cu� , f"l J�. � <br /> Will this be a Parade of Homes, Remo�d lers Showcase Home or other Dis lay 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 service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��� <br /> State License# Expiration Date: `� �j� � <br /> Lead Certification Number: ��-� - � 3 )S -O�/—OC�;��' � Expiration Date: a f �S� I S <br /> (for work on homes thatwere constructed prior fo 1978 <br /> Phone: y`� v�' ��C"� — ��,v 1 (office) (L,l ��- �(.�b - �,�� (cell) <br /> Mailing Address: �, � ,���,r� City: y� � ZIP: S S 3 <br /> Contact Person: ��� ���Qv Applicant is: ont actor / Homeowner (Circle One) <br /> Email and/or Fax: G��a-�'('o�- �y 3 3 <br /> PROPERTY OWNER INFORMATION: <br /> Name: ^���,� �,^�'� <br /> Phone(day): (���- �Sq- ?s90 <br /> Address: � � c � ,��,ti� City: �a��y ZIP: �S^3s�� <br /> Email and/or Fax o c�k � ^�a� . �''� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ 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.orq <br /> Overall Project Description: c:..�r 0�F �.� �F� �� J'e. t �,.>� v�c...� <br /> Estimated Construction Valuation of Project(excludin land) $ j U�. c,,G� <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 lication ma not be issued. <br /> ApplicanYs Signature: Date: ����1� <br /> Last Updated: 08-09-2011 <br />