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City of Orono <br /> Building Permit Application for Maintenance I Renovation <br /> {windows, doors, siding, re-roof, etc,} <br /> Mailing Address: Permit number: D/ �e ' I <br /> ay 0 PO Box 66 <br /> � Crystal Say, MN 55323-0066 Date received: <br /> I <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee' <br /> Orono, MN 55356 <br /> Main: 952-249-4600 Fes ,piJ� Total Fee: <br /> ' 952-249616 www.ci,orp�o7n. <br /> This application form must be completed in full and all required Information must be submitted. <br /> Incomplete appiicatlons will be returned. (Please print) <br /> GENERAL INFORMATION; ��O� � TN C) <br /> Job Site Address: _ __ _ CSC L-, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes ❑ No <br /> N 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-stme parking Is available- Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: tYl [S l -,&,A A �rSe N <br /> State License# Expiration tate: f <br /> Lead Certification Number: �--�1 �-a g -_1_ Expiration Date: I f 5 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (0S 1— a gff- per„ (office) (call) <br /> Mailing Address, IgGta CC), weg+ City: ZIP: SS1 3 <br /> Contact Person: Applicant is: [Contradowl / Homeowner (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name; Lx- <br /> ty-el;n-e— fvyG n <br /> Phone(day); <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door s El Remodel Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,asphalt i ❑ Repair ❑Storm Damage 18202 Minnetonka Blvd <br /> © Re-roof,cedar ❑ Restoration D Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑Re-roof,other(specify) Siding ❑Other (specify) Fax' 952-471-06$2 <br /> El Window(s) I �r <br /> www,rninnehahaeek.org <br /> Overall Project Description* k ( V; pc tJS W e ry -e X;S "rte <br /> Estimated Construction Val uati6k cf Project(excluding land) $ 8,6p <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 I <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 agenci&s <br /> required by law. If ou refuse to supply the information the application may not be issued. <br /> ADDlicant's Sionature: 6;_Y� Date: Is �� <br />