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City of Orono <br /> r Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> �� Mailing Address: Permit number. o? (���J '��o <br /> %�,L,0,� PO Box 66 <br /> , �,�:., 0 <br /> Crystal Bay, MN 55323-0066 Date received: —v� —� <br /> �I,a '' ��:,?fy reet Address: Received by: <br /> � ' �"�' ti 2750 Kelley Parkway Plan review fee: <br /> t9'kESH��� Orono, MN 55356 <br /> Total Fee: <br /> Main: 95 49-4600 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: 07�9 1� r���/Y ,�V4 <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No <br /> If yes, a specral evenf permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicanf demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: j7'1t1�1�(. ��^S�D:�C�.��� L,L� <br /> State License# ��� i,, 3 g/5�,� Expiration Date: 3� 3/ � /`! <br /> Lead Certification Number: � - I - 3C'S3�y._ /I ' t,�/G>G�7 Expiration Date: Z -iy_ �� <br /> (for work on irom ucfed prior fo 1978 <br /> Phone: �SJ - �7/3- �� � (office) (cell� <br /> Mailing Address: � 3 `r' 7 S Clf€�t�:�� p; City: ,y�.�,�d G� ZIP: �— <br /> Contact Pers�n: mq�k mEN�c� Applicant is;�"�ontractor Homeowner (CircleOne) <br /> Email and/or Fax: n•� n,�f ...,tc� 6 MS�• �e M <br /> PROPERTY OWNER INFORMATION: <br /> Name: CN.����5 /�ck:,..y <br /> Phone(day): • <br /> Address: aL�i�i K�l��/ ��� City: ZIP: <br /> C)a� � <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-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) �A��=�� ��Y�il � �✓w.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ �� �;� a�� <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 applicafion 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: (�� a�, J�d'Z <br /> Last Updated: 08-09-2011 <br />