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. <br /> � � <br /> city of Orono <br /> Buiiding Permit qpp�ication for Maintenance 1 Renavation <br /> (windows, doors, siding, re-roof, etc.j <br /> �O�\ Mailing Addr�ss: <br /> \ PO Box 66 Permit number. p�� /� / <br /> Q Q\, Crystal Bay, MN 55323-0086 Date received: _ <br /> �� ' �, Street Address.• Received by: <br /> ��� OronoKMN 55356 y P�$n reviewfee: <br /> � <br /> Main: 952-249-4600 Fax: 952-249-4616 Total Fee: �7� <br /> rn�.ci.orono.mn us ��,v(./ <br /> This apptication form must be completed in#ulI and all required ir�formation must be submitted. <br /> Incomplet�applications wi11 be r�eturned. (P/ease print) <br /> GENERAL lNFORMATIOfV: - <br /> Job Site Addreas: �Q • �� <br /> �II this be a Parade of Homes, Remodelers Showcase Home or ather sptay Home? y� <br /> Hyres,a specia!evenf pennit is required with Police Deparfinent and City Couqqil approyal BO de <br /> required un/ess appljcairt demonstrafes sufiffcier►t on.s/te g 1'3 Prror fo the evenk ShutHe 6us service will be <br /> parldn is available. NorFpermitfed events will notbe al/oweal, <br /> CONTRACTOR 1 APPLICANT INFORMATION: <br /> Name: /�,��.�T7���, � T 1`�' � . <br /> State License# �'�°z`����' <br /> a c Expiratian Date: �^�'/- �� <br /> Lead Certification Number: � <br /> 1? ' r r Expiration Date: �� �� �.���� <br /> (for worh on homes�et rvere coristruMed pyor 1 78 <br /> Phane: r�,�f- (office) '--�"t S'� < S��,C` � � (ceU) <br /> Mailing Address: �- r <br /> Contact Person: City: ZIP:�j'"`� .5-- <br /> - Appticant is: Contractor / Homeowner {circls one) <br /> Email and/or Fax: ��.� <br /> PR�PERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): ' ,� <br /> Address: �, �-�.� City: 2fP: <br /> Email andlor Fax <br /> PROJECT tNFORMATION: <br /> Type of Project: <br /> Any earth movement may require <br /> ❑Door(s} ❑ Remodel ❑Fire Damage MCIND review�permits; <br /> ❑Re-roof,as halt Minnehaha Creek Watershed District(MCWD) <br /> P ❑Repair ❑Storm Darrrage 18202 Minneto�ka Blvd <br /> roof,cedar ❑Restoration ❑Vilater Damage Deephaven,MN 55391 <br /> ❑Re-roof,other fs�ec�[y) ❑Siding ❑Other. s eci Phone: 852-471-0590 <br /> � p fi') Fax: 952-471-0682 <br /> ❑Wirtdow(s) vy�.minnehahacreek orn <br /> Overal!Pro"ect D�scrl tion: <br /> Estimated Constniction Valuatlon of Project(excluding land) $ <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Ce�tifies that the ir�formation supplied is true and corract to the best af his/fier knouNedge. The applicant recogn¢es that they <br /> are solety responsibte for submitting a complete application befng aware that upon failure to do so, the staff has no a�ematiae <br /> but to rejact i#un�7 it is complete; <br /> • Some or all oP the information that you are asked to provide on this application is classified by State iaw as either <br /> confidential. Pmrate data is information whicti generalfy cannot be given to the public but can be given io the subject of the <br /> data. Confidential data is information which generally cannot be 8iven to either the pubfic or the subject of the data. Our <br /> purpose and intended use ot this information is to annually update our rec.orcls and records of other govemmental agencies <br /> re uired law. !f u refuse to 1 ' n,the a licafion ma not be issued. <br /> ApplicanYs Signature: Date: l t�� .�G(� <br /> L2stUpdBted: Q8-09-201ti <br />