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, . � � II <br /> City of Orono <br /> Building IPermit Application for Maintenance / Renovation� II <br /> _ �T� � a5 <br /> (vinndows, doors, siding, re roof, etc.) , <br /> Mailing Address: Permit number: � —� 7 <br /> O4.r�.�0 PO Box 66 <br /> I� Crystal Bay, MN 55323-0066 Date received: /D-Z — (Z <br /> � - Street Address: Received by: <br /> �'� G�`� 2750 Kelley Parkway Plan review fee: O�a —0/ 7 <br /> '�Rg�Hag4' Orono,MN 55356 ,r�., <br /> Total Fee: `3�� �1" <br /> Main: 952-249-4 0 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This applicationl 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: / f�I�{ZSTd G�/,� /�� , <br /> Wtll this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No I� <br /> If yes,a special evenf permit is required with Police Department and City Council approva160 deys pnor to the event. Shuttle bus sernce will b�e <br /> required unless applicant demonslrates sulricient on-site parking is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPUCANT INFORMATION: <br /> Name: �.��r � ��, �� <br /> State License# �C �Z.� �l�[� Expiration Date: 3 / ! <br /> Lead Certification Number: Expiration Date: 2 Z <br /> (for work on homes that were constructed pNor to 1978 <br /> Phone: g,sZ- ? - (office) !2- ,S - (o Q (cel) <br /> Mailing Address: Za 3 G✓� !�/A� Z�T��9 Lf/�� 7� ��tY� Gon/ L�,��P� S �o <br /> Contact Person: ?" �/t � � Applicant is: Contracto / Homeowner (Circle One►', <br /> Email and/or Fax: ��r�� ,� .��a�,�S �r /1 DrN�S < C a n� '� <br /> , a <br /> PROPERTY OWNER INFORMATION: <br /> Name: � � ��2 ��.l,t �LL/S I <br /> Phone (day): r <br /> Address: ��,��� City. Z�p: I�� <br /> Email and/or Fax + <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require i <br /> ❑ Door s �Rerroodel MCWD review 8 permits: I <br /> O ❑Fire Damage Minnehaha Creek Watershed District(MCWD) i <br /> ❑Re-roof,asphalt ❑RepBir ❑Storm Damage 18202 Minnetonka Blvd � <br /> ❑ Re-roof, cedar ❑Restoration ❑Water Damage Deephaven,MN 58391 I <br /> Phone: 952-471-0590 <br /> ❑Re-roof, other(speciTy) ❑Siding ❑Other:(speafy) Fax: 952-471-0682 <br /> ❑Wind�ow(s) www.minnehahacreek.orq ', <br /> Overall Project Description: �rG� 2�C o 1lflst'Iv�•( ✓v�s}-t�L �doF" ,Z �2 <br /> Estimated Construction Valuation of Project(excluding land) $ �. � c1,c��b� � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; I� <br /> • Certifies that the infortnation supplied is true and corred 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 altemativei� <br /> but to reject it until it is complete; � <br /> • Some or all of the informaUon that you are asked to provide on this application is classified by State law as either private or�� <br /> confidential. Private data is infoRnaUon which generally cannot be given to the public but can be given to the subjed of the i� <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 tMis 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: Q d2- <br /> last Updated: 08-09-2011 <br />