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City of Orono <br /> Building Permit Application for Maintenance / Renovation <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: c).(26-.)/...) —Ue) 5., <br /> ‘----4c:::07-4 . PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: f . !l <br /> --P.- Street Address: Received by: <br /> Il' t ; i' 0.;." 2750 Kelley Parkway Plan review fee: <br /> L"1kESHO�� Orono, MN 55356 <br /> Total Fee: <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 r turne (Please print) <br /> GENERAL INFORMATION: O C Pk 2c <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes []� <br /> if 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-site parking is available. Non-permitted events will not be allowed, <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: /..o 04%9 r ..S crX4I('oI S L <br /> State License# jC- 3 S 4K ( Expiration Date: 0.301 /20/,s' <br /> Lead Certification Number: NAT _ /o03 &6 - I Expiration Date: 0Z/2/ /?o/C7 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: 763 '•fzS - o oS (office) (o(L 61-14( - 0Zg 6 (cell) <br /> Mailing Address: 1(30g 70 +P PG r. City: 4 /t:groie ZIP: <br /> SS..S%'9 <br /> Contact Person: AAeo... Applicant is: CContr / Homeowner (Circle One) <br /> Email and/or Fax: 763 - WS"- G l rP S <br /> PROPERTY OWNER INFORMATION: <br /> Name: <Ev;i Lei^1 <br /> Phone (day): C (otC) 96`1 76 <br /> Address: ,6/S Qc cA-r-e-C2 All e City: 4 e-- ZIP: s--s-3s 6 <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> El Doors MCWD review&permits: <br /> ( El ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑roof, asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ Re roof, other(specify) Phone: 952-471-0590 <br /> E Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Overall Project Description: E r- of( rec.) P o-J Adus AJ gq.r-4 F_ <br /> Estimated Construction Valuation of Project (excluding land) $ gy5p _ _of <br /> �` <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 c.it•• •- given to the public but can be given to the subject of the <br /> data. Confidential data is information which get,- . cannot be, given to either the public or the subject of the data. Our <br /> purpose and intended use of this inform. is to annually mate our records and records .• -other governmental agencies <br /> required b law. If ou refuse to su.• • the information, plication may not be is - . c q <br /> Applicant's Signature: Date: < U / Zt>/Z <br /> Last Updated: 08-09-2011 <br />