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� V City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address a�l�_�!/
<br /> ���� PO Box 66 Permit number:
<br /> /0 O�, Crystal Bay, MN 55323-0066 Date received: l� /
<br /> / �;,,,, , 1
<br /> �,a � '}' �� �., � StreetAddress: Received by:
<br /> l��r/i 2750 Kelle Parkwa
<br /> \�t � ���, p Y Y Plan review fee:
<br /> � � � � Orono, MN 55356
<br /> ESHo4/
<br /> --� Total Fee: � C' , ��i
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us J�� �"
<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: � �j ,� ���.��",,/',✓•1'...3 �/'I�f/''�
<br /> Will this be a Parade of Homes, Remodelers Showcase 1-�ome or other Display Home? ❑ Yes No
<br /> If yes, a special event permit is required with Police Department and City Councif approva/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 INF�O M TION:
<br /> Name: ,,�'•.;�;,.�:.. ,j/'�,�d`'r G'a�fj�'�' .:.,a �. � � �'i'�./`
<br /> State License# ,2 t�G�r�ryt7� Expiration Date: .�`�f,-��`!�!,�_r,
<br /> Lead Certification Number. Expiration Date: ` �
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: �� .,�._ �������a�;;7 (office) (cell)
<br /> Mailing Address: City: ZIP:
<br /> Contact Person: ; /,,!�- Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ,/�"i'�il,��°�� ��Gt,.+,�',...�'.� ,�' �"�/C�
<br /> Phone (day):
<br /> Address:iZq(�✓� �a�� /fU y ���j�,_ City•,/„i��'� ZIP:
<br /> ,F"�
<br /> Email and/or Fax �
<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:
<br /> Estimated Construction Valuation of Project(excluding land) $ � �jCjd
<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 /> I • 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 /> ,r ' �' ��„�__
<br /> . ���° �
<br /> ApplicanYs Signature: �� �.,�`,��!'.��`�°F ,,`y�' Date: `.''`�c"% � /�
<br /> Last Updated: 08-09-2011
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