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<br /> � � � City of Orono
<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.)
<br /> �—�\ Mailing Address: Permit number: - -�� ( �..
<br /> �v 0,�`� PO Box 66 �
<br /> Q � 0��, Crystal Bay, MN 55323-0066 Date received: J — — �
<br /> �°',-.� . 1
<br /> a '� �°' '�=�, �, � StreetAddress: Received by:
<br /> �'� � t s�,,,� ��% 2750 Kelley Parkway Plan review fee:
<br /> L'�gESK�j/ Orono, MN 55356
<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. (P/ease print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �i�S ��,,zS -� �}✓,-�,,; L�r��
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> /f yes,a specia/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: l,.:r,�,��-1 �-�- �,�-�z c° rv�'�5 _I-v,c .
<br /> State License# S(c�c ��y � Expiration Date: 3 -- ,3 r - /Z
<br /> Lead Certification Number: �,� c��;��� _ � Expiration Date: (� _ �� _ � S .�
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: ��,3_ �(�j 3 . � �a� (office) (cell)
<br /> Mailing Address: �� M�� � I City: ,�� ,� ZIP: ��j
<br /> Contact Person: �,�� Applicant is t Homeowner (Circle One)
<br /> Email and/or Fax: ���.L�,��� ��;�S � .�,.�.
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ��i��o✓-� Sl,�zh� �..�
<br /> Phone (day): J r
<br /> `�S r� �`-t �<�- I `�I �-
<br /> Address: City: ZIP:
<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 /> Re-roof, as halt Minnehaha Creek Watershed District(MCWD) �
<br /> � p ❑ Repair � Storm Damage 18202 Minnetonka Blvd
<br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
<br /> ❑ Re-roof, other s eci Phone: 952-471-0590
<br /> ( p fy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682
<br /> ❑Window(s) www.minnehahacreek.orq
<br /> Overall Project Description: TU,-_�����J �-r�_rv�.� ���,,�..,z e.�.l ��{��(,,_�� ��,�:�
<br /> Estimated Construction Valuation of Project(excluding land) $ (�� �� �'=
<br /> ,
<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 licati ma not be issued.
<br /> ApplicanYs Signature: �— � � Date: /�--�-�//
<br /> Last Updated: 08-09-2011
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