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. <br /> �� � ��� <br /> City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: 6 -- <br /> .¢,�,�j.\ PO Box 66 <br /> L � Crystal Bay,MN 55323-0066 Date received: <br /> 0�,��"�' O '� Received by: <br /> a � { , �, Street Address: <br /> '�,�, ;� f"� �~ 2750 Kelley Parkwa� Plan review fee: <br /> 19x���ag� Orono,MN 5535§ � r <br /> Es� �__ - � \ <br /> --— Total Fee: � �, /}� ) <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us I— <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: �-'; ��r? �v . �C vr �f• <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 Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: �L.�J �ic�c�-�C C�„��-�'�:�"�+vr� <br /> State License# �p(��-� �-�� Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: � Z, -�-I$� � 3��� (office) (cell) <br /> Mailing Address: � Ci�:__ „�; ZIP: <br /> Contact Person: �,J� �,�,��,� Applicant is� ontractor / omeowner �ci.�ie o�e> <br /> Email and/or Fax: �<<,,�.cu�,..� � w�sv� c:..��,,_� <br /> PROPERTY OWNER INFORMATION: <br /> Name: -�c�.n��c.�. �c-�.�u►�n <br /> Phone(day): c�rj.-Z_ �c��� r�'jo-� <br /> Address: ti'�j�t C �. �.r,, �,r-, City: i;•r-at�� ZIP: ��, 3E�-� <br /> Email and/or Fax <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 /> �({2e-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 /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ �¢�oop <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 applica[ion being aware that upon failure to do so, the staff has no altemative <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 s 1 the information,the a lication ma not be issued. <br /> ApplicanYs Signature: •.,,.�, Date: ��►'Z-1� y <br /> Last Updated: 08-09-2011 <br />