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O�T-13-�011 06:49 From: 6785736615 To:952z494616 Pa9e:1�1 <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, sidin , re-roof, etc.) <br /> Mailing Add�ess: Permit number: -.O/oZ � <br /> O.�D�O PO Box 66 <br /> Crystat Bay,MN 55323-0066 Date received: /�/ / <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plen review fee: <br /> �i� �� Orono,MN 5535B <br /> Total Fee: �Q3 4�•�/ <br /> Main: 952-249-4800 Fax: 952-249-4B18 www.a.orono.mn.us <br /> This application form must be completed in full and all�equired information must be submitted. <br /> Incomplete applications will be retu�ned. (P/ease print) <br /> 6ENERAL INFORMATION: . <br /> Job Site Address: �� �- �� � <br /> Will this be a Parade of Homes� Remodelers Shawcase Home o othsr Oisplay Home? Yes o <br /> 1!yss,a special event permit is reqai�ed w�Oh Police Department and City Cauncil appivval 80 days prior to dhe e�nent Shuttle bus seivice will be <br /> required unless applicant demonstrates sufr�cient on�sile paricing is avaiyable. NonyoemnYted ewnts will not be a/lowed. <br /> C4NTRACTOR/APPLIGANT tNFORMATION: <br /> Name: ;^ <br /> State License# ZuS�3 6 S` F_xpiration Date: <br /> Lead Certification Number. Expiration Date: <br /> (io►work on homes U►at woere eonsbuci+ed prior to�978 <br /> Phone: . . e�� (office) (cell) <br /> Mailing Address: City: � ZIP: �3� <br /> Contact Person: s�,,�i p„� Applicant is: Contractor / Homeowner �c��ie one► <br /> Email and/or Fax: �� A ���,,� �,p�`{��,�... . u�.. • <br /> PROPERTY OWNER INFORMATION: ' <br /> Name: � '$,�,�,Z,� <br /> Phone(day): ����qy S - IL3 � <br /> Address: a5 Lv�,C,�, I..+�i�, �t,,Gd,e� Clty: ('�/aN..� ZIP: s3' 3�' <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑Remodel ❑Fire Damag� MCWD review b permits: <br /> ,_.,L Minnehaha Creek Wabershed DisVict(MCWD) <br /> Q12e-roof,asphalt ❑Repair I�torm Damage 18Q02 Minnetonka Blvd <br /> ❑Re-roof,cedar (�Restoration ❑Water Damage Deephaven,MN 55391 <br /> Phone: 952-4�1-0590 <br /> ❑Re-roof,other(specify) ❑3iding ❑Other(specify) Fauc: 952-471-0682 <br /> ❑Window(s) �ww.minnehahacreek.ora <br /> Over�ll Project Description: <br /> Estimated Construction Valuation of Project(excluding laod) S 1'�� b�'�• (ps <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • aqrees to provide sll ir�orm�tion required or requested by the Building Department; <br /> • Certifies that the informetion supplied is true and coRect to the best of his/t►er knowledge. The applicarrt rscogni�es that they <br /> are solely responsible for submitting a complet�application bsing avwr�th�t upon failure tv do so, tho staff has no alternative <br /> but to rejad it until it is camplate; <br /> • Some or all of the infonnation that you are esked to provide on this eppllcation is dassified by State law es either privete or <br /> confiderrtial. Private dets is informatian which generally csnnot be given to the public but can be given to the subjed of the <br /> data. Confidential data is infoRnation which �enerally cannot b� given to either the public or ths aubject of the data. Our <br /> purpose and intsnded use of this informadon is to annually update our reoonfs and records of other govemmental agenaes <br /> re ui�ed b �aw. If u rafuse to su I ihe informatian,the s lication ma not be issued. <br /> n��r�..�a..,e+s......a�....- l 1 , C JI� / � n..a.... � .� � 1'� � 1 � <br />