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<br /> . , City of Orono h �y � `
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<br /> Building Permit Application for Maintenance / Renovation
<br /> (windows, doors, siding, re-roof, etc.) �
<br /> Mailing Address: "� �.:
<br /> �,0,�. PO Box 66 Permit number: ��%!�— ;
<br />, ' O Q Crystal Bay, MN 55323-0066 Date received: / �
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<br /> �> Received by: "�
<br /> a �' �;4�,� �. Street Address: �
<br /> �S',�, 1 t p6���, G� 2750 Kelley Parkway Plan reviewfee: "�t
<br /> L N" � Orono, MN 55356 ,�
<br /> 9'kESHO�` '�
<br /> - Total Fee: ��� � �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br />�i 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: `; =i ; ,� �-, �f� �f„-` /J� -�
<br />"� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �-bo- �
<br /> If yes, a special event permit is required with Police Departmenf and City Council approval 60 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.
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<br /> CONTRACTOR/APPLICANT INFORMATION: , �
<br /> Name: - ^,,� L -�
<br /> State License# ��j� y Expiration Date: ,j a 6 /a �
<br /> Lead Certification Number: � � �� Expiration Date: �
<br />�:;;; (for work on homes that were constructed prior to 1978 �'�
<br /> ; ` Phone: ��� -�l 3 S .-. �� ,f�` (office) (cell) �
<br /> 4 � Mailing Address: ��O � � � k ��y City:���,,.�,J� �� ZIP: ��- � � �
<br /> a ` Contact Person: �' , � Applicant is: Contractor / Homeowner (Circle One) �
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<br /> f r�i Email and/or Fax: 4 S-J ^ ���s-- - �'G 4 y �
<br /> �_ ����� PROPERTY OWNER INFORMATION: �';
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<br /> � Name: �l4 �,�,e;� ;�
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<br /> Phone (day): ��
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<br /> �' Address: -7 � p _ � , Cit ZIP:S�,S' �Sv� �{
<br /> 4 ' v, t-� �r.� r� t' Y� � �_,l u �
<br /> Email and/or Fax ryk.
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<br />' � PROJECT INFORMATION: �a
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<br /> Type of Project: Any earth movement may require �
<br /> �'� MCWD review&permits: �
<br /> � ❑ Door(s) ❑ Remodel ❑ Fire Damage
<br />°� Minnehaha Creek Watershed District(MCWD) �
<br /> ��roof, asphalt ❑ Repair orm 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) Fax: 952-471-0682 �
<br />� ^ ❑Window(s) www.minnehahacreek.orq ��
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<br /> Overall Project Description: ,�
<br /> ` ` Estimated Construction Valuation of Project(excluding land) $ � ������ � ��
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<br /> APPLICANT ACKNOWLEDGEMENT: ��
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<br /> Agrees to provide all information required or requested by the Building Department; �;
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<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 ofi 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: _ �X�i` Date: �/�G/o�v // ;�
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<br /> • Last Updated: 08-09-2011 �'
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