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/ '' � .� / <br /> City of Orono (P ' <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> -- Mailing Address: ��_�� � <br /> /�0 PO Box 66 Permit number: o�L� <br /> �� <br /> ,!� Q� Crystal Bay, MN 55323-0066 Date received: � / / oZ <br /> �� ��� � �� Received b ��/a�� �� <br /> il a ,��'r+�,� a,;, Street Address: y <br /> ���'� ��'��'� ��� 2750 Kelley Parkway Plan review fee: ���,3 � <br /> ���9���'^� � g� Orono, MN 55356 <br /> �,kEs�o� ao�� - o� `f g <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 SiteAddress: yp,:-� � �..l�v��, �v�;�, {`��,� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑x No <br /> lf yes,a special event permit!s 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: �oNL�.Pt ��tn •�s��o....v+ <br /> State License# �j C ��p�� Expiration Date: 3 - 3� _ i.� <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes thaf were constructed prior to 1978 <br /> Phone: �5� -�tl� - +i i►8 (office) !�►� �S� ��,�"�,� (cell) <br /> MailingAddress: 3`�3 � : � 2 City: �o;��� ZIP: 5:;�,� <br /> Contact Person: J�y.,l 5�„� �T,� Applicant is: Contracto / Homeowner (Circle One) <br /> Email and/or Fax: �h.�,.,�,�� �`�� � �.'c�,n��ec n�"� t��e"�' <br /> PROPERTY OWNER INFORMATION: <br /> Name: {�;L� ttGwSf. <br /> Phone(day): ���, ���, ��8,; <br /> Address: �}0 51 {-������,fao� R� City: �Ra�� ZIP: �S'��,y <br /> Email and/or Fax «�s z�. s�,y � u�1 . `�� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) � Remodel ❑ Fire Damage MCWD review 8�permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt � Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Re-roof, cedar ❑fc Restoration ❑Water Damage Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Siding � Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) c.,k t �o, t, <br /> www.minnehahacreek.orp <br /> Overall Project Description: ' <br /> Estimated Construction Valuation of Project(excluding land) $ �o oG ! <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 /> required b law. If ou refuse to su I the information,the application ma not be issued. <br /> ApplicanYs Signature: _ �, Date: � _�$ - �z <br /> Last Updated: 08-09-2011 <br />