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�, _ _ <br /> , �� Y ; ,�.. � <br /> � � - � �:� <br /> � , � City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: //-C'/a <br /> �,0,�. PO Box 66 � <br /> Crystal Bay, MN 55323-0066 Date received: Z/ � <br /> � ��, 0 . <br /> ° Received b �,� <br /> ,� � �'� ,� Street Address: y� <br /> �',�c,t t �b;„q„ �ti 2750 Kelley Parkway Plan review fee: <br /> �kESHO�`'� Orono, MN 55356 <br /> �__� <br /> - Total Fee: � ��/_ �, / h� <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us (/J, ��- <br /> .a <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) �± <br /> GENERAL INFORMATION: <br /> Job Site Address: %��j ��'��j �jQ/�� �'. � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No � <br /> /f yes, a special event permit is required with Po/ice Department and City Council approval 60 days prior to the event. Shutt/e bus service wil/be � <br /> required unless applicant demonsfrates sufficient on-site parking is available. Non-permitted events will not be allowed �; <br /> t� <br /> �, CONTRACTOR/AP,PLICAcN�T INFORMATION: �� <br /> Name: �bfi� m,oa n�I �/C1 Si')C,. � <br /> State License# 2p 172 �� 3 � Expiration Date: ZO/� � <br /> Lead Certification Number: Expiration Date: �� <br /> (for work on homes that were constructed prior fo 1978 � <br /> Phone: ��3_��S p _ (office) (cell) � <br /> � <br />� �� <br /> Mailing Address: S'S6 Q � City: ` � p ZIP: SS'3 7 � <br /> Contact Person: 'Sp v� �h t�i�c l 'r� Applicant is: Contractor Homeowner (Circle One) � <br /> Email and/or Fax: - � <br /> �m� �rs� �'�iYlca s�, �i E'f'_ <br /> <� <br /> PROPERTY OWNER INFORMATION• / ` <br /> Name: C✓� � JC'�1/1i��% �/%�QPI� � <br /> Phone (day): �_ ' _ g- Q � <br /> Address: Z(�SS /v0�'J� ��e �✓'• City: �,��,7 n ZIP: ,5`�53�/ <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage <br /> MCWD review&permits: '� <br /> 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 /> ❑Window(s) www•minnehahacreek.orq <br /> Overall Project Description: T�t_�t � ��� ; f <br /> Estimated Construction Valuation of Project(excluding land) $ g 1 , p p <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 govemmental agencies �` <br /> re uired b law. If ou refuse to su I t1e i m tion,the a lication ma not be issued. <br /> ApplicanYs Signature: f � Date: �-Z��� <br /> Last Updated: 08-09-2011 <br />