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! City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re.root, etc.) <br /> Marling Address: Permit number: i,i(C(7' C(� - <br /> PO Bax f36 y > -i----- <br /> 1 <br /> 7 <br /> Q I Date received: ,� <br /> �"<$° '�� Crystal Bay,MN 55323-0066 ! <br /> Received by: /vt u"`- ----�� <br /> �r„ Street Address: <br /> 4.79 <br /> 2750 Kelley Parkway Plan review fee:Orono,MM 55356 G ...0,,Q- <br /> -461 <br /> �qg . - Total Fee: 4�`7 / U 0 <br /> Main: 952-2494600Fax: 952-2494616 . .or•1•_m ...s <br /> , <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: 31.3 5 -ck,nncS %ti.. I"c.).Job Site Address: 1111 <br /> Will this s a Parade of Homes, wit ith p llee D patttrnnent ens c�Council approevalC60 day prior to the event.Shutle bus service will be <br /> If yes,a specie!event permitC <br /> required unless applicant demonstrates sufficient an-opts policing is available. Non-permitted eventr3 will not be allowed. <br /> CONTRACTOR l APPLICANT INFORMATION: <br /> Name: ..?-re. -Wo.\ - 0 •,e'C ' Expiration Date: 'S 1 51 <br /> State License# �C,1�a09 a Expiration Date: Y� � <br /> Lead Certification Number: (vj j - a'+•a$3 <br /> (for work on homes that were constructed prior to 1978 (cell) <br /> C.,phone: (b51- alp -40'T ;- .a..(office) CI v'1 , Ztp: '3 <br /> Mailing Address: 1• . b , t • '� `' w= " City: .m,,, . <br /> Applicant Is: 0, •r / Homeowner (circle One) <br /> Contact Person: <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: , \ <br /> Name: <br /> Phone (day): `)5'• City: j ZIP: <br /> Address: <br /> Email and/or Fax <br /> PROJECT INFORMATION: , <br /> Any earth movement may require <br /> Type of Project: MCWD review&permits: <br /> 0 Door(s) ©Remodel ©Fire Damage Minnehaha Creek Watershed District(MCWD) <br /> Storm Damage 18202 Minnetonka Blvd <br /> ©Re roof,asphalt ❑Repair 0 Deephaveh,MN 95391 <br /> 12 Re-roof,cedar 0 Restoration 0 Water Damage Rhone: 952-471-0590 <br /> 0 Other:(specify) Fax: 952-471-0682 <br /> (_]Re-roof,other(specify) Siding mi ha c e _or <br /> 0 Window(s) <br /> __Overall project�escri•tion: ,, , ' C.t.. . ..+. �. k' +.. <br /> Estimated Construction Valuation of.Pro'e_ct(excludln! land . " " . <br /> AFP DANT ACKNOWLE._GFM.ENT: <br /> • Agrees to provide all information required or regl>tieated by the Building Department; i <br /> recognizes that they <br /> • Certifies that the Information supplied is true and correct to the beet of his/her knowledge. The applicant8 <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 ciatfified by State law as either private or <br /> confidential. Private data is Information whih generally <br /> l Gannet bbeggivenven to a therpublic <br /> pu but <br /> can or the e given <br /> to subject the <br /> the data.subject <br /> eta Our the <br /> data. n intended <br /> ddata Is information whichgenerally <br /> purpose and intended use of this irttorrnetion is to annually update our records and records of bother governmental agencies <br /> -•uire• b law. If o refus- to su••I the info ation the a.•iicatlon Ma not be issued, <br /> .D Date: 5 0C-41.)1;a4 I I <br /> Aoolicant's Slanature: / <br />