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v <br /> I� .iS <br /> City of Orono �' <br /> 0 � <br /> Building Permit Application for Maintenance / Renovation . �� <br /> ' (windows, doors, siding, re-roof, etc.) a; <br /> — t� <br /> Mailing Address: Permit number: � '" <br /> O�,D,�.O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: � <br /> �r <br /> y i Received by: � <br /> ,� �;-�; �, Street Address: <br /> �',�, t ""� �ti�' 2750 Kelley Parkway Plan review fee: <br /> t9kESH�4� 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 /> Incomplete applications will be returned. (Please print) '�`` <br /> GENERAL INFORMATION: , � <br /> Job Site Address: __ ��� ,���'� �j 7`- <br /> Will this be a Parade of Homes, Remodelers 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 demonsfrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> ��� <br /> CONTRACTOR/APPLICANT INFORMATION: � <br /> Name: 1�'��'?`�/,� �c'•�Sf/l'l/G�i l�/� <br /> State License# �o lA 3,���� Expiration Date: 3i_�j�j � `. <br /> Lead Certification Number: Expiration Date: �T� '' <br /> (for work on homes fhat were constructed prior to 1978 °%' <br /> Phone: (office) (cell) �� <br /> '-� <br /> Mailing Address: ,�������)����� �y� City����j�'����,�. ��, .S_ � � j, <br /> Contact Person: �� Applicant is: Contr ctS or / Homeowner (CircleOne�Z►� � <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: '� <br /> Name: ������/,�l�,�jl �-'� SC�.C� � <br /> Phone (day): ' �� ,� <br /> Address: ���� J City���,�� ZIF': � 5 �j� � '� <br /> Email and/or Fax <br /> � <br /> � <br /> PROJECT INFORMATION: a� <br /> �� <br /> Type of Project: �" Any earth movement may require >" <br /> ❑ Door(s) �f�� ❑ Remodel ❑ Fire Damage MCWD review&permits: � <br /> �� Minnehaha Creek Watershed C)istrict(MCWD) �: <br /> �'Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka 131vd ' <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 5�391 G`� <br /> Phone: 952-471-O:i90 ��` <br /> ❑ Re-roof, other(speciry) ❑ Sidin � <br /> g ❑ Other: (specify) Fax: 952-471-06£�2 <br /> ❑Window(s) www.minnehahacree<.orq �" <br /> :<;� <br /> Overall Project Description: � <br /> Estimated Construction Valuation of Project(excluding land) $ �� .�o '' <br /> g <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 re�;ognizes 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 ��f the data. Our � <br />'::;'_E purpose and intended use of this ' formation is to annually update our records and records of other governmental agencies '� <br /> , � re uired b law. If ou refuse to I the information,the a lication ma not be issued. �� <br /> ': , _ �y ._.____._ {. <br /> ApplicanYs Signature: � � Date: �' � ' <br /> ;:� <br /> Last Updated: 08-09-2011 ;'� <br /> .� <br /> .. � �. ._ -- - -� <br />