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City of Orono <br /> Buiiding Permit App�ication for Ma�ntenance 1 Renavation <br /> (windaws, doors, siding, re�roof, etc.) <br /> M�lling Address: Permit numt�er. �O��� _ .� <br /> Q��'`~� Crysfal Bay, MN 55323-0066 Date rece(ved: .Jr�J��� <br /> �' Sfreet Addr'ess' Fieceived by: <br /> ,� �' ��-� � <br /> '� • �� � �/ 2750 Keiley Parkway I Pian review fiee: <br /> Z����oq,rv Orono, MN 55358 �/ <br /> �_ � Tota1 Fee: � � <br /> Main' 952-2dB-4600 Fax= 952-249-4618 v�w��.ci.��:,no.I;7� i <br /> Thls application form rnust be completed in fuEl and all required inform�tion must be submitted. <br /> Incomp{ete applicatlons wil! be returned. (Please pr�rtt) <br /> GEN�rtAL lNFORMATION: ���� (` �+, S �1 ( I� � � � <br /> .lob Site Address: �''�� <br /> Wil{thls be a Parade of Horr�es, Remadelers Shawcas�Home or o#her Dlsplay Hor�te? Yes No <br /> lf yes,a speoial evsn[�ermit is requfred wlth Police Departmsnt artd CPty Counci!approvsl 60 days prlor to tha ev�nt. Sh1�ttJe bus service wld be <br /> required unless applicant demonstrar�s su�cianf on�slte parking is�vallable. Non permlttad events wll!nof 6e ailnwsd. <br /> CONT}2ACTOR J APPLICANT iNFC7i7MAT10N: <br /> Name� �r,�.�s.��.o � �1v�d��s�e� r <br /> State License# ��.1'3t��� Expiration Date: � ('3s <br /> L.ead Certiflcation Number: � '�� �'�a�3 - Expiration Date; � <br /> (inr xrork on homes that were constrrrci�ed Arfar to i978 <br /> Phone: f.�S}�- c��At.�_�.��- � � (of€ice) {cell) <br /> Mai}ing Address� �,1p1'�t'� r C� �t� "G„ L�..le� V CitY'�S�.t,S�'►1� zIP� SS <br /> Gonta�t Person: Applicant is: �ontr�ctor / Homeowner (CiYG�e One) <br /> Email and/or Fax: — <br /> PROPEFtTY OWNER INFORMATION: <br /> Narne: (�S <br /> Phone (day): �S�-�� ��'�' <br /> Address: �� Ci�+: ZIP: <br /> Emali and/or�ax y <br /> PROJ�CT INFORIV[ATION: � <br /> Type ofi Project: Any earth mov�ment may require <br /> MCWD revlew 8 permits: i <br /> ❑ Daor(s) ❑ Remodal ❑Fire D�mage M��nehah8 Creek Watersheci Dlstrict(MCWD) <br /> ❑Re-roof, a�pheit Q Repair �]Sform Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Re-roo#,cedar ❑ Restoration ❑Wat�r Damage pnd�e: 952-471-0590 <br /> �R�roof,ather(specify) �Siding [�Other:(spectfy) Fasc: 952-471-0682 <br /> �� 5 � 1 wVna�.:ninn i,a;�acreek.or <br /> j�Window(s) <br /> Qverall Project Descrlption: Q,,,kSo C� W1�+��� Q�"'`; . <br /> Est{mated Construction Vaivatian of Pr�o;ect(excluding fand) � 4/ .0 <br /> APPLICAN7 ACKNOVIiLEDGEMENT: <br /> . Agrees to prov€de all information requfre or requested by ihe�uilding Department; <br /> . Certifies that the information supplled is tru� and correct ta the best of hislher knowledge. The applicant rFacbgni�es that they � <br /> are sofely respdnsible for svbrnitting a complst� �pp[lcation being aware that upon fallure to do so,the staff has na alternative I <br /> bUt to reject it untl�it is compiefe; � <br /> ' • Some or all of the infarmetton that you are asked to provide on thls application Is classified by State law as either privats or <br /> canfEdentiai. P�ivate dats is informatian whlch generally csnnot be given tn the public but can be given ta the subject of the <br /> data. Confidential data is information which general(y cannot be giv�n ta elther the public or the subject of the data. Qur <br /> purpose and intende� use of this information is to annually update our records and rr�cords of other governmentaf agencies <br /> re uirsd b Eaw. If ou ra#use to su I ihe Fnforma#ion the a lication ma not be issued. M„ <br /> Ao�licant's Sianature: Gy-�--� �ate: ��p u� /� <br /> � � <br />