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. ��,v � i���a� <br /> City of Orono `2 � RFc <br /> ���FO <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.. <br /> _ <br /> Last Updated: 08-09-2011 <br />