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� � �7 <br /> ` n 20 � Cit of Orono / ��� <br /> � i / Y <br /> Building Permit Application for Maintenance / �enovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: pZ0//-0/ <br /> .¢,�,�. PO Box 66 <br /> O � O Crystal Bay, MN 55323-0066 Date received: / / — / <br /> �. <br /> a, �, „��„ a, Street Address: Received by: <br /> '�',F, � �v �ti�' 2750 Kelley Parkway Plan review fee: �p.3�. � <br /> r9kE8H�g'� Orono, MN 55356 a �/- / `7 <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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ,�4���' ,q �,,,,g �'�,�dno � <br /> Will this be a Parade of Homes, Remodelevs 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: ���.h �x�e.�,_e��s <br /> State License# �� � y o� �,35- Expiration Date: 3 - �/ - a d/a <br /> Lead Certification Number: _���� '�y S 3 S— / Expiration Date: �_ � - �p�5 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: s (office) �/ a . (cell) <br /> Mailing Address: < < '� City: �„", (�,,, � ZIP: — p <br /> Contact Person: n yji(;� Applicant is: tractor / Homeowner �ci��ie o�e> <br /> Email and/or Fax: � ,� ' <br /> PROPERTY OWNER INFORMATION: <br /> Name: c% ,� t �M,s� �,� .. <br /> Phone(day): _ <br /> Address: „ City: ZIP: <br /> Email and/or Fax j��Q � ),,,,� 1 /� mQ� . ��n.. <br /> PROJECT INFORMATION: <br /> Type of ProjeCt: Any earth movement may require <br /> 0 Door(8) �model ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Re-roof,asphalt [•�Repair 0'S�orm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other(specify) �ding ❑Other: (specify) Fax: 952-471-0682 <br /> indow(s) <br /> www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ f'U yy � <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: ��_ � Date: /�j - / �_ �p /� <br /> Last Updated: 08-09-2011 <br />