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1 1 w <br /> City of Orono <br /> Building Permit Application for Maintenance 1 Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> �� Mailing Addiess: <br /> �"��T PO Box 66 Permit number: <br /> Q �; �� Crystal Bay, MN 55323-0066 Date received: <br /> �- I <br /> � �, � Slreet Addiess: Reoeived by: <br /> '�'lq `,�o'` 275Q 1(elley Parkway Plan review fee: <br /> ��sao4` Orono, MN 5535fi <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci orono mn us Total Fee: <br /> This application form must be completed in full and all required information must be submitted. <br /> lncompiete applications will be returned_ (Please print) <br /> GENERAL lNFORMATION; <br /> Job Site Address: l S �� �� ��(������V� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes �No <br /> Kyes,a special event permit is required with Polrce Depariment and City Counci!approval 60 days prior to the event. 5hutt/e bus service wi11 be <br /> requi�ed unless applicant demonstrafes sufficient on-site parfcingls avaNable. Non-permrtted events wiN not be adowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��uJo.� �l �Av�-tYS�rv <br /> State License# �,G`309$3 Expiration Date: 3 �3� <br /> Lead Certificati�n Number: (`j ~r_ a� as3 _ Expiration Date: <br /> (for worlr on homes that were constructed erinr�,..�q78 ��15 <br /> Phone: (a S j� a�— L.�O�� (office) <br /> Mailing Address: ,. „ ����� <br /> 19 v"1 C . � C l�es�- City:�yk �lle. zIP: SS1 <br /> Contact Person: Applicant is: oniractor / Homeowner <br /> Email andlor Fax: «�'��One� <br /> PROPERTY OWNER INFURMATIO • <br /> Name: ���� '�O���} <br /> Phone (day); Q a , a - <br /> Address: <br /> Emaif and/or Fax <br /> + C ity: ZI P: <br /> RROJECT INFORMATtON: <br /> Type of Project: <br /> Any earth movement may requtre <br /> ❑ Door�s) ❑Remodel ❑Fire Damage MCWD review�permits: <br /> ❑Re-roof,asphatt ❑Re air Mfnnehaha Creek Watershed District(MCWD) <br /> P ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑Re-roof,cedar ❑ Restoration ❑Water Damage �ePhaven, MN 55391 <br /> ❑Re-roof,other(spaciry) ❑Siding Phone: 952-471-059Q <br /> ❑Other: (specify} Fax; 952-471-0fi82 <br /> ❑ Window(s) www.minnehahacreek ora <br /> Overal) Project Description: � �� <br /> Estimated Construction Valuation of Project (excludin la d � � �S a , _ <br /> 9 � 1 9 , O <br /> APpLICANT ACKNOWLEDGEMENT: <br /> • qgrees to provide all inforrnation required or requested by the Building Department; <br /> • Certifies that the infarmation supplied is true and correct to the best of his/her knowledge_ The applicant recognizes that they <br /> are sole�y responsible for submitting a complete application being aware ihat upon failure to do so, Ihe staff has no alternaiive <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 classifred by State !aw as either private or <br /> confidential. Private data is infurmation 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 informakion 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 /> Aoolicant's Sianature• ryv,,, l� <br /> Date: �� i ����} <br /> C/ <br /> z 'd 06T9bL91S9 3�IA213S 1IW213d Q '8 S �1 LS �zT ETOZ BO FeW <br />