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_ �z <br /> City of Orono <br /> . �y <br /> • Building Permit Application for Maintenance / Renovation �� <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: <br /> 4v�,� PO Box 66 _a <br /> Crystal Bay, MN 55323-0066 Date received: <br /> O �f�� O Received b � <br /> a � >�f> s, Streef Address: y� �; <br /> �'.�c, a„w,j„_ Gti 2750 Kelley Parkway Plan review fee: `� <br /> L9kESHFog'� Orono, MN 55356 _ ' <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. &T <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: (�(7 /(���r�. f�rv, 2c <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,� No ,� <br /> If yes, a special event permit is required with Pofice Department and City Council approva160 days prior to the event. Shuttle bus service will be ' <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. '� <br /> r A u:< <br /> ,.....:.J� <br /> CONTRACTOR/APPLICANT INFORMATION: _`� <br /> Name: ��,�. � <br /> State License# �C_ (e �? -ljdGS Expiration Date: 3� � �� <br /> Lead Certification Number: _��p Expiration Date: � <br /> �"K <br /> (for work on homes that were construcfed prior to 1978 .,� <br /> Phone: ��1_ ,j,2�, 7�� (office) (cell) � <br /> Mailing Address: City: ZIP: - G � <br /> Contact Person: Applicant is: / Homeowner (Circle One) ';� <br /> Email and/or Fax: �=;� <br /> � <br /> -,� <br /> PROPERTY OWNER INFORMATION: v�# <br /> Name: rn�-� l��� � <br /> Phone (day): �`3 G� � <br /> Address: _��c���� w �� � City: ��,�1� ZIP: � � <br /> Email and/or Fax <br /> .� <br /> �� <br /> PROJECT INFORMATION: � <br /> Type of Project: Any earth movement may require <br /> ❑ Door s MCWD review& ermits: ': <br /> ( ) ❑ Remodel ❑ Fire Damage p <br /> Minnehaha Creek Watershed District(MCWD) � <br /> 18 Re-roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd � <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 � <br /> ❑ Re-roof,other s eci Phone: 952-471-0590 � <br /> ( p fy) ❑ Siding ❑ Other. (specify) Fax: 952-471-0682 �� <br /> ❑Window(s) www.minnehahacreek.orq ` <br /> 2� <br /> �:; <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ �d�s� �� � <br /> G <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 the information,the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �- .3 '� <br /> _--- <br /> Last Updated: 08-09-2011 <br /> rxk <br />