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-ht' u 2g 2012 1 : 09PM Berkshire Home Solutions 783-432-9854 p. 1 <br /> City of Orono �k F-60 2___, <br /> Building Permit Application for Maintenance I Renovation <br /> .,sal. {/IA)11 . (windows, doors, sidin , tie-root etc.) <br /> Mailing Address: Permit number: / r <br /> Ap PO Box 66 <br /> O 4 0 Crystal Bey,MN 55323.0069 Date received: 25_ <br /> Street Address: Received by: <br /> k 1i�, ��i,/i; 4, 2750 Kelley Parkway Plan review fee: <br /> "1' i100 Orono, MN 85356 <br /> Total Fee. 1 / 7 w, 7`c-.J .f- cA,d0 <br /> Main: 952-249.4600 Fax: 952-249-4616 www.rjigrarno.mnu! <br /> This application form must be completed In VI and all required Information must be submitted. U <br /> Incomplete applications will be returned. (Please print) V <br /> GENERAL INFORMATION: <br /> Job Site Address; 6 to b,„1.1 Ramb. 2.15_ o.r+w c S;S( -91:43 <br /> Will this be a Parade of omes,'Remodelers Showcase Home or other Display Home? Yee ViNo <br /> If yes,a sporequired uevent nlessaprequired t demonstrates sufficient onrtment®nd City Council ate per�np s available,/No days <br /> prior to the tltted events willnotbe allowed. Nice will be <br /> CONTRACTOR/APPLICANT INFORMATION; <br /> Name: Sae l/rt►bi 44• 4. cauck ' <br /> State License# Ri:L Zi1 Expiration Date: '3 /4414 <br /> Lead Certification Number. ,j __ ill-va` - 1 Expiration Date: G / t j?01r <br /> (for work on homes that were construded prior to 1978 <br /> Phone: - .. , (office) % _ i - ,t — (cell) <br /> Mailing Address: ., , . _ City: A ,_ ZIP: <br /> Contact Person: . •pplicant is: ontr-cto I Homeowner (cirw•one) <br /> Email and/or Fax: lit �),&„ mow, <br /> PROPERTY OWNER INFORMATION: <br /> Name: bc....lY+ 1 Phone(day): 6t? , 34 1-292(a Clty:�wK� ZIP: tt�S(o-OIL�3 <br /> Address: j wed ,('e,�y- el <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permIte: <br /> ❑ Door(s) ❑ Remodel ❑Fire Damage Mlnneheha Creek Watershed District(MCWD) <br /> XtRe-roof,asphalt CE Repair 5aStorm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55361 <br /> ❑Re-roof,cedar 0 Restoration ❑Water Damage Phone: 952-471-0580 <br /> ❑Re-roof, other(specify) ❑ Siding 0 Other: (specify) Fax: 952-471-0682 <br /> CI Window(s) • <br /> vmww.minnehaha.reek.orq <br /> Overall Project Description: , 4%eu. 0e4 I. <br /> Estimated Construction Valuation of Protect(exclu ng I nd) $ Q30iD.m <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 /> ere 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 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 /> required by law�lfyou refusefto thisinformation <br /> the Information,thalsppl�lcaton may not beate our records ess�d,nd records of other governmental agendas <br /> Applicant's Signature: F/1''� ..- Date: sy2.q 1 i2. <br />