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<br /> • ' City of Orono �
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<br /> .- Building Permit Application for Maintenance / Renovation �
<br /> (windows, doors, siding, re-roof, etc.) �:'.
<br /> Mailing Address: Permit number. a�l�'���D� �
<br /> O�,�,�.0 PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: � U � ' ��
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<br /> �°>'�t� y. �i
<br />` �a � �.; s, S t r e e t A d dre ss: Received b {
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<br /> F� • �'�t � t �,�,„�„ �ti�' 2750 Kelley Parkway Plan review fee:
<br /> �kESHo4•� Orono, MN 55356
<br /> � -- Total Fee: v3 ��, ��
<br /> �' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<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 /> L ' GENERAL INFORMATIO •
<br />`���' ` �I � � �. �Iti.�l�
<br /> Job Site Address: � +- '� ��.r-e
<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 s rvice will be
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. � ti�
<br /># �:: CONTRACTOR/A Pi CANT IN ORMATIO : � , ��
<br />� ,: Name: av�: a��. ` �: � C>✓� �
<br /> State License # , (� '� 7� ` Expiration Date: �p �2 ��
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were cons ructed prior to 1978- 1 Y�{q
<br /> Phone: (�( �-Z Z ( - (office) (cell)
<br /> Mailing Address: 5' -C' ( ( . City: ��,,,, ��. . ZIP: �` 3 �
<br />�. Contact Person: �' � Applicant is: Contractor � Homeowner �c���ie one>
<br /> 7�; ,
<br />�ti, Email and/or Fax: , _ � � � �„ �___._____--' `
<br /> -� PROPERTY OWNER INF RMAT ON: , 7 �
<br />�° Name: M;C; Cz� � �/lJr l f C'�C�. �
<br /> ` Phone (day): (�(2_ _ �3 �
<br />� Address: �(J ,� � � City: � � - , ZIP: ,� 3 � � �
<br /> Email and/or Fax � �,,� � . � � �
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<br />�,' PROJECT INFORMATION: �
<br /> Type of Project: Any earth movement may require
<br /> MCWD review& ermits:
<br />� , ❑ Door(s) ❑ Remodel ❑ Fire Damage p
<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 />`��.'. indow(s) www.minnehahacreek.orq �
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<br /> Overall Project Description: ,, - . b o ` — ,� - -- �
<br /> ��Estimated Construction Valuatio of Project (excluding land) $ Q , � (� Y,3
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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
<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; ,t.
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<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 r ords and records of other govemmental agencies
<br /> re uired b law. If ou refuse to su I the informatiory;the licatiom m �ot be issued. �
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<br /> ApplicanYs Signature: Date: � �
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<br /> Last Updated: 08-09-2011
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