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<br /> �, ,►, . City of Orono
<br /> � Building Permit Application for Maintenance / Renovation `
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<br /> (windows, doors, siding, re-roof, etc.) ��
<br /> �`O MailiPO Bo�r66 � Permit number: _ � �
<br /> �y �0 Crystal Bay, MN 55323-0066 Date received: _ / ;�
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<br /> - ,� � � `: �, Street Address:
<br /> Received by: �
<br /> �`` �' "l ��� ti 2750 Kelle Parkwa
<br /> c� p� �, Y Y Plan review fee:
<br /> L9kE mog'� Orono, MN 55356 -�
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<br /> Total Fee: /� ':
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ��D� �`� ;�
<br /> This application form must be completed in full and all required information must be submitted. '�
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<br /> Incomplete applications will be returned. (P/ease print) �
<br /> � GENERAL INFORMATION: �
<br />,, , JobSiteAddress: ��J�-V L_��' � +1`1���m 1���,��. �,`Vv'� va� Y �� w1�i �
<br /> Will this be a Parade of Homes, Remodelers S wcase 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 demonstrates sufficienf on-site parking is available. Non-permitted events will not be allowed. �
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<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> �, Name: ��iiv1? 'C �2 C�n es �i^r�S�'�-C-'�l�1 �
<br /> State License# �C o�1 3 �-o o Expiration Date: �o��. 3\ ! 261 � `�
<br /> Lead Certification Number: N�P,�_ ������� - � Expiration Date: �(�����1� 2d l ip
<br /> (for work on homes fhat were constructed prior to 1978 _
<br /> Phone: ��j � �-}�1 2 �ji,;;^1 c (office) l.P �2S� � 2\� l (cell) �
<br /> Mailing Address: '� � � ��y� flvi �_ � City: __.,_._ _ a�v. ZIP: -rj'�j 3�
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<br /> Contact Person: �}e-�-�,4,..� y���5,�.� Applicant is: ontractor Homeowner (CircleOne) �
<br /> Email and/or Fax: �'�Gj-� �� Z ��io`I o i_� �
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<br />{�A PROPERTY OWNER I�FORMATION: :w
<br />� ��� Name: � a b��� ��
<br />�; Phone (day): S� �� � - ���� � ;
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<br /> Address: ��2v �� ,�� � fi� �� City: �� c,�,-r�ZIP:
<br /> Email and/or Fax ��
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<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, as halt +�
<br />;� , � p ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd x
<br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 �;;`
<br /> Phone: 952-471-0590 �
<br /> ❑ Re-roof,other(specify) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 `�
<br /> ❑Window(s) www.minnehahacreek.orq v
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<br /> Overall Project Description: �i"� ,�\,�c°.rr�- (- co �- . � 3SQ V�c�r L. , x
<br /> Estimated Construction Valuation of Project(excluding land) $ �'�� G,�= ,w
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Department;
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<br /> • Certifies that the information supplied is true and correct to the best of hislher 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 ' formation which generally cannot be given to either the public or the subject of the data. Our
<br /> purpose and intended use o this information is to annually update our records and records of other governmental agencies
<br /> re uired b law. If ou refu e o su I th i ormation,the a lication ma not be issued.
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<br /> ApplicanYs Signature: Date: ���— �2
<br /> Last Updated: 08-09-2011 �
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