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� ,� City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: � <br /> �,�,�.\ PO Box 66 <br /> Q .� �\ Crystal Bay, MN 55323-0066 Date received: �/ <br /> �� �,,:, �,� <br /> .� ��� a. I Street Address: Received by: <br /> '�'�c, ���F� °ti � 2750 Kelley ParkwaY Plan review fee: <br /> L9��xog,� Orono, MN 55356 � <br /> -'__' Total Fee: �/ � ,?j�. �,� <br /> Main: 952-249-4600 Fax: 952-249-4616 www ci.arono.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 /> � <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase ome 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 evenk Shuttle bus service will be <br /> required un/ess applicant demonstrates su�cient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR 1 APPLICANT INFORMATION: <br /> Name: ���/ro �u�`�G�lDti �"�l %trt� �'o. <br /> State License# C_ Expiration Date: 3-. �_ �2 <br /> Lead Certification Number: Ex iration Date: ��—�— <br /> /V' r- 90 �sq - ! p � -- �o � 5 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: � (office) • � � (cell) <br /> Mailing Address: Cit : S" ZIP: <br /> Contact Person: �r `d��.f Z Applicant is: Contrac or / Homeowner (Circle One) <br /> Email and/or Fax: eG ��To , l.1.. . Co/� , <br /> PROPERTY OWNER INFORMATION: <br /> Name: �f�2e ���! rg-�Z <br /> Phone (day): ����G?. G gG8 <br /> Address: ` , L!� c Ri�`A� City:�f..�A ZIP: `Cz'b�`�.�'GT <br /> 3o L ���-� <br /> Email and/or Fax ��� ���,n !�/rla orn �� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD�eview 8 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 /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) ❑ Sic�ing ❑Other: (specify) Fax: 952-471-0682 <br /> a••� www.minnehahacreek.orq <br /> �y'window(s) <br /> Overall Project Description: W ' s <br /> Estimated Construction Valuation of roject(excluding land) $ /�/�./4�'G /sD <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 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 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 th 'nfor ion,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: /,�-' �--,?Ol/ <br /> Last Updated: 08-09-2011 <br />