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<br /> Cit of Orono �� ' � ���
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<br />� Building Permit Application for Maintenance / Renovation � �
<br /> (windows, doors, siding, re-roof, etc.)
<br />� Mailing Address: �
<br /> Permit number: 02���• (�`d
<br /> g,�,�. PO Box 66 �
<br /> � Q Crystal Bay, MN 55323-0066 Date received: �
<br /> �
<br /> a � ��; �, Street Address: Received by: '
<br /> �,�, t 6'�''" ti 2750 Kelley Parkway �
<br /> Plan rewew fee:
<br /> r9kESH��`'�G Orono, MN 55356 ��� � A�
<br /> — Total Fee: �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �
<br /> ��
<br /> This application form must be completed in full and all required information must be submitted. M�
<br /> Incomplete applications will be returned. (Please print) �
<br /> GENERAL INFORMATION: ��
<br /> Job Site Address: !.�j(�� ��;G �' ��� J�vL v�� jJiZ �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �J No �
<br /> If yes, a specia!event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be �s
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. ��`�
<br /> ,;�',,,,��:.
<br /> CONTRACTOR/APPLICANT INFORMATION: �"
<br /> Name: p. f�.�Z �'�,�z�)� ;��
<br /> State License# -, � Expiration Date: "�
<br /> Z�.. c��-7(_ 3�� ('�'�/3 i � i3 �
<br /> Lead Certification Number: Expiration Date:
<br /> �n
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: "7l,3 - ��3�-1?I-7 (office) (cell) �4
<br /> Mailing Address: r�C� ��o� 3$s 3 5� City: S;a r�� �C��al� ZIP: �S 37�. '��
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<br /> Contact Person: �� A licant is: C t a�c o�i ��/ Homeowner �
<br /> � � i�l� (_G. 1.l�,�.�C� PP (Circle One)
<br /> Email and/or Fax: ��� - �3 f�'`c t 3� `�
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<br /> PROPERTY OWNER INFORMATION:
<br /> Name: 1��1-�c•, � �c�a.� SEGc� /� ������-o��
<br /> Phone (day): L, ('Z - Z 7 c� C, ? �'��+ �
<br /> Address: i�� 4 � �` ,",. �t-y� !t-� ��. � ,IJ.. City: �,�. �,`, �, ZIP: �,
<br />, Email and/or Fax a_;
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<br /> PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require �
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits: �,'
<br /> ❑ Fire Damage 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) Fax: 952-471-0682
<br /> �� www.minnehahacreek.orq �
<br /> j ❑Window(s)
<br />��i Overall Project Description: �2 F �,y�c,�,,F ��.� ��I�'�c'� t���
<br /> Estimated Construction Valuation of Project(excluding land) $ /Z� c�rc� , c�C,
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<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 ,t�
<br /> ,{ are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative ��
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<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 mformation which generally canno�be given to the public but can be given to the subject of the �
<br /> data. Confidential data is information which generally canrrof�be given to either the public or the subject of the data. Our �
<br /> purpose and intended use of this information is to annu�lly update our records�- n'd records of other governmental agencies �
<br /> re uired b law. If ou refuse to su I the informati�h,the a lication ma no,t�e issued. ,..�
<br /> ' -` . €i;
<br /> �; Applicant's Signature: i" � '�.__-- - Date: ����jl ��
<br /> �� ��
<br /> = Last Updated: 08-09-2011
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