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<br /> City of Orono `2 � RFc
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<br /> Building Permit Application for Maintenance / Renovatior�r��,� � ,
<br /> (windows, doors, siding, re-roof, etc.) y2��2
<br /> ��, Mailing Address: F
<br /> /�,�,�0 PO Box 66 Permit number: Q 0
<br /> / � Crystal Bay, MN 55323-0066 Date received: a- _ a-
<br /> 1 " �,,�,..
<br /> Received by:
<br /> a Z •, :. �, Street Address:
<br /> �'� � '� G� 2750 Kelley Parkway Plan review fee:
<br /> ��g�Hog� Orono, MN 55356
<br /> �_-_-"/ -7
<br /> Total Fee: � S109. `�
<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: '� 17 ��f3o^�++ ��t;;`
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display 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: �irRM �'►.��� c'�rN o..,� ,<a:�.+:c.,
<br /> State License# �2�:.�0;� Expiration Date: o,;j j,/L,�;,�
<br /> Lead Certification Number: n�.�r- za��+G- 1 Expiration Date: o;.���� (tc;�
<br /> (for work on homes that were constructed prior fo 1978
<br /> Phone: "�7 2 . �-I i z. 99�r1 (office) ��'L.338 aG.c.� (cell)
<br /> Mailing Address: ��,, w[.�Y�A'iA 3�L� City: S;, �v�:s az�( ZIP: ��s�l'L�
<br /> Contact Person: L.�.,,� .�,�a.,��,� Applicant is: Contractor / Homeowner �c�►�ie one�
<br /> Email and/or Fax: c��Z y���, qag�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: 3,.,,,� ;,�.a�c.:ar � +G3r,�;r S:J,��r..�,.�,�
<br /> Phone(day): yyz, �f 3 . �l��19
<br /> Address y 7� /��+3o2.4r� Daw� CitY: c3kv�.,o ZIP: ;�>3Sy
<br /> Email and/or Fax ��,�3i,�;�e+M�.�v C� c��,� �,�,�,�
<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 /> ❑ 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: r<�:c�+c:v 2E'�c'�i.L .:V�:w „4��[• :Jo-� Q�Mc�.�z �� N�,�,- 6c�a,,,c,, :�,aL�
<br /> Estimated Construction Valuation of Project(excluding land) $ •Z�y, ��
<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: i'� ��"'-- Date: /z/�_�z..
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<br /> Last Updated: 08-09-2011
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