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<br /> City of Orono
<br /> Building Permit Application for Maintenance / Renovatio
<br /> (windows, doors, siding, re-roof, etc.) /��•�S -
<br /> Mailing Address: Permit number: apl�-DO�
<br /> O��,�.0 PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: - -� ��
<br /> "�,
<br /> ,� � ��-�, �, Street Address: Received by: �.5
<br /> '�, �' A �..�' 2750 Kelley Parkway Plan review fee: ���� -�O"�J �"'
<br /> 19,�E$H�g'� Orono, MN 55356 ���� �
<br /> �_- Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 . �
<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: �l�-]y }'�� i,�r���'�s��!�c� �ic�j�v��:� L�v�c� �%T�%%`�c:�,d�l� S-=����
<br /> Will this be a Parade of Homes, Remodelers Showcase Home r other Display Home? ❑Yes �No
<br /> /f yes,a specia/event permit is required with Po/ice Department and City Counci/approva/60 days prior to the event. Shutt/e bus serv�c wi//be
<br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events wil!not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION: \
<br /> Name: _�r�'ic'i�.-F /�F=� =c%�����.J ✓) E�r'�
<br /> State License# Expiration Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: �S Z_�S-_f�,S�Z (o�ce) ��SZ ZI S-(�?�� (cell)
<br /> Mailing Address: �— = ,� y - y. �- City: -� -� ZIP: � ��� ,
<br /> Contact Person: �16����, �,�- �.�,���, ,.� Applicant is: Contractor / omeowrier �c�.�ie o�e�
<br /> Email and/or Fax: ���� �}�a � �,�,�� ����,r,���,�
<br /> PROPERTY OWNER IN�RMATION:
<br /> Name: r:J �r�'{' ���� J�✓)
<br /> Phone(day): �� ��Z-�f ZC�•-,l �{�Z
<br /> Address: /,.,7`� i�'l i ,�►��-�o,�kct �-�'���.n d ���i z C�tY�C'}�;t�v ZIP: �S``��(c�
<br /> Email and/or Fax b�+ k m i- k c� a� �Nl �h�!„�u���
<br /> PROJECT INFORMATION:
<br /> Type of Project: Any earth movement may require
<br /> ❑Door(s) Remodel ❑ Fire Damage MCWD review 8�permits:
<br /> � Minnehaha Creek Watershed District(MCWD)
<br /> ❑Re-roof,asphalt ❑Repair ❑ Storm Damage 18202 Minnetonka Blvd
<br /> ❑Re-roof,cedar ❑Restoration ❑Water Damage Deephaven, MN 55391
<br /> Phone: 952-471-0590
<br /> ❑Re-roof,other(specify) ❑Siding ❑Other: (specify) Fau: 952-471-0682
<br /> ❑Window(s) '"`�"�N- -, ��'i , ee�,,ra
<br /> Overall Project Description: �� ��, E: �. � �3
<br /> Estimated Construction Valuation of Project(excluding land) S �Q, C�C��
<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 Gassified 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 /> r uired b law. If ou refuse to su I the information,the a lication ma not be issued.
<br /> ApplicanYsSignature: � � /��i�-�, Date: ���f�/�
<br /> T
<br /> Last Updated: 08-09-2011
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