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1 <br /> City of Orono F-7-/C6tiel <br /> Building Permit Application for Maintenance I Renovation <br /> (windows, doors, siding, re-roof, etc.) _ <br /> _ p Mailing <br /> Box 86 Per_number: 48/317--/Nei <br /> r 6(• Crystal Bay, MN 55323.00613 Date received; /4=33A rf <br /> ,�' y���11 street Address: Received by: <br /> ` > ,rr'_�d 2750 Kelley Parkway Plan review fee; �� e <br /> _ - •a� Orono, MN 55356 �•J/ <br /> • <br /> Main: 952-249-4600 Fax: 952-249-4516 wworono.mn•us Total Fee: <br /> v,ci, <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: 11153 /►f 147-A-1, .4,--- <br /> Win this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes z o <br /> If yea,a special event permit is required with Police Department end City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates Sufficient on-site perking Is available. Non-permitted events will net be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: k6 , 1.., r-J r l l <br /> State License# 1tG �6 Expiration Date: '. ..,-//,18.' <br /> Lead Certification Number , --517. - - Expiration Date: r21 <br /> (for work on homes that were constructed prior to 1078 <br /> Phone: ,'t ';, ,r (office) (cell) <br /> Mailing Address: } 30- City: , #„, ZIP: Oq <br /> Contact Person: MI Applicant Is: ontractor / Homeowner (ctrat•on.y <br /> Email andlor Fax: ' f1N 6✓LvPr( M ry ,h-% <br /> PROPERTY OWNER INFO ATION: <br /> Name: r'5w_r+ . A 06111dilleS <br /> Phone(day): ' ' -, - 4 , - <br /> Address: J S3 Ai 'r- -• 4, City: 00/'-ry ZIP: 5--5-3‘q <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑Door(s) 0 remodel ❑Fire Damage MCWD review permit;; <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,sephait ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> 0 Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof, other(specify) ❑ Siding 0 Other:(specify) Fax:%Windt -ml cAtiata <br /> • <br /> Overall Project Description: 541-4- (4, , <br /> Estimated Construction Valuation of P oJect(excluding land) $ S--1r./ I <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 few as either private or <br /> confidential. Private data Is information which 8enerally cannot be given to the public but can be given to the subject of the <br /> date. 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 /> required by law. If you refuse to supply the Information,the application may not be issued, <br /> Applicant's Signature: G----- 2.-r 7 <br /> _ Date; <br /> Last Updated; 08-09-2011 <br /> 1 'd Xid3 13rN3Sd1 dH Wd9I :E LTOZ 22 21U <br />