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���y o� Orono <br /> ' ' ' Buifding Permit Appiicatio� for Nlaintenance / Renovatio� <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> �„L,0,� PO Box 66 <br /> � �,s � \ Crystal Bay, MN 55323-0066 Date received: <br /> a, °' � �, Street Address: Received by: <br /> �'.� ' d� ti� 2750 Kelle Parkwa <br /> o y y Plan xeview fee: <br /> L'�kEsxog� 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 /> fncompiete appfications will be returned. (P/ease print) <br /> GENERAL INFORMATION: i� "�� <br /> Job Site Address: �L(p��J 1�-e �� �-t � , ...i� <br /> Will this be a Parade of Homes, Remodefers Showcase Home or other Disp{ay Home? ❑ Yes o <br /> !f yes, a specra/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service wil!be <br /> required unless applicant demonsfrates sufficient on-site parking is available. Non-permitted events wil/not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATIOI�: <br /> Name: ����✓� V JS� <br /> State License # ( �,,-,�L;(, T � Expiration Qate: <br /> Lead Certification Num er: Expiration Date: <br /> (for work on homes that were constructed prior fo 9978 <br /> Phone: a��^�,U-7_c:��_�,.�t3 (office) (cell) <br /> Maifing Address: ���,�, � t�`r`�� ��- � ( City: ������ ZIP: ;,c,�� <br /> Contact Person: ���- ����1`� Applicant is: Contracfor'� Homeowner (Circle One) <br /> � <...._..___.._ <br /> Ernail andbr Fax: -- <br /> PROPERTY OWNER INFORMATION: <br /> Name: '-��J`L c�+� �cti�+� ��3��' <br /> Phone(day): � <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 Qamage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> �e-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) i www.minnehahacreek.orq <br /> Overall Project Description: � � .��,�� v .� f� _ r-. � <br /> Estimated Construction Vafuation of Project (excfuding land) $ � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a compfete appfication 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 informafion that you are asked to provide on this application is classified by State law as either private or <br /> confidenfiaf. 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 fo 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 supplv the information,the a ficati ma not be issued. <br /> �-----� <br /> ApplicanYs Signature: ���_r�_Y Date: / --I� <br /> � � (��i <br /> Last Updated: 08-09-2011 <br />