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Nov 1: 2 08:22a Kaufman Roofing 612-722-1021 p.1 <br /> � <br /> City o� Orono <br /> B ilding Permit Application for Maintenance 1 Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Marling Address: Perrt3it number: ���� <br /> .�0 PO Box 86 <br /> Crystal Bay, MN 55323-0086 Dafe received: -- q <br /> �t � Str�aet Address: Received by: <br /> �• 2750 Kelley Parkway Plan review fiee: <br /> ��oyy Orono, MN 55356 <br /> Total Fee: � �--7(�' � <br /> Ma : 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> T is application form must be completed in fulf and all required information must be submitted. <br /> Incomplete applications will be returned. (Please pri�t) <br /> GE RAL INF RMATION� <br /> Job iteAddr s: 4 Z�� �`t�+M►,J �-:�,. � ! <br /> Well is be a P rade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes �No <br /> If es,a speda,event permit is requlred wlfh Police Deparfment and City Councll approval 60 deys pri'or to the everrf. Shu1Ne bus serv�ce wiN be <br /> r '�ired uNess app/icanf demonstrafes s�aent on-site paNcing is evaifable. Non-permrtfed events wil!not be allowed. <br /> CON,TRACTOR! PLICANT INFO�TION: ' <br /> Name: ��..�,� e� :;,� <br /> State License# [��j��q�� Expiration Date: � <br /> Lead Certi#ication Number: ��-; Expiration Date: <br /> (for wo�k on homes ihat were canstructed prfor to 1978 <br /> Pho�e: ��l2 ��Z. . c�q�.� (o�ice) �'��--3t,�3 � 1 bo� (ce��) <br /> Mailing Address: ' -� �� �, City: � ZIP: y�ti, <br /> Contact Person: Applicant is: ontractor 1 Hameowner {c��ieo�e� <br /> Email and/or Fa�: , .� ,�,� � -_ � . , �,, <br /> PROPERTY OWNER INFORMATION: <br /> Name: j �=t,�., ,��L,�3s�, <br /> Phone (day}: , Gr l Z_�+�{�a.C�.'3�"� 5'�3ct ( <br /> Address: I �Z�(C• L`�,�►,��a.,� Lti•,cr� City: Cj���; ZI P: <br /> Email andJor Fax <br /> PROJECT INFORMATION: <br /> Type of Project Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage � MCWD review 8�perrnits: <br /> Mi�nehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,aspha�lt �Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> �Re-toof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other jspecffy) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.ora <br /> Overall ProjectjDescription:�` �,� i�.�.�,� �;F R�c,F � � - i+�s,{,,�c.. �.a��� <br /> Estimated Construction Valuation of Project(excluding land) $ `Z��Ct UA "= <br /> APPLICANT AICKNOWLEDGEMENT: <br /> . Agrees t provide all information required or requested by the Building Department; <br /> • Certifies t�at the info�mation supplied is true and correct to the best of his/her knowledge. The applicarrt recognizes that they <br /> are solefy� responsible for submitting a complete applicaiion being aware that u�on failure to do so, the staff has no alternative <br /> but to rej�ct it until it is compfete; <br /> • Some or II of the iriformation that you are asRed to provide on this appfication is classified by State law as either private or <br /> confidenti�l, Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Cqnfidential data i ' formation hich ge erall cannot be given to either the public or the subject of the data. Our <br /> purpose �nd intended e this info tion i t a n ally update our records and records of other governmerrtal agencies <br /> re uired b law. If ou efus to s I t info ,t e a lication ma not be issued. <br /> I � � <br /> AnnliranYc Ginn�t�ira• . oate: '1 I I`! i� <br />