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.,� � � ��� �� <br /> r �; <br />€ ■ . . . � ����{ z* <br />� �� � � C ity of O ro n o <br /> Y,� <br /> Building Permit Application for Maintenance / Renovation � rr <br /> ��#`: <br /> (windows, doors, siding, re-roof, etc.) � <br /> Mailing Address: �' <br /> �,�,� PO Box 66 Permit number: �ll—O/l� v� <br /> � <br /> � � � <br /> Crystal Bay, MN 55323-0066 Date received: �� / � <br /> a �� �_;�; �, � StreetAddress: � Received by: � <br /> �',�c,t � ��'� Gti� 2750 Kelley Parkway Plan review fee: � <br /> �` � i Orono, MN 55356 <br /> �'kESH�4 —� <br /> Total Fee: �5 /� � <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 /> a;= Incomplete applications will be returned. (Please print) __:� <br /> , ;� <br /> GENERAL INFORMATION• � �,� <br />��'� Job Site Address: Ct,�r' (\ � � <br /> �f: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o '�; <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 wil!not be allowed. ''�- <br /> � <br /> CONTRACTOR/APPLICANT INFORMATI . �� <br /> Name: �_ `�� �� � <br /> State License # � c �� <br /> � �` Expiration Date: _�; <br /> Lead Certification Number. Expiration Date: � <br /> (for work on homes that were construcfed i to �78 '�' <br /> ��. �� <br />°�� Phone: i � �%( a � ti (office) , (cell) � <br />��; Mailing Address: City: <br /> _ �,\ QIP: ; � <br /> Contact Person: Applicant i : Contractor / Homeowner �c��oie o�e� � <br /> � Email and/or Fax: � <br />:�" <br /> PROPERTY OWNER INFORMATIQN: <br /> t <br /> _� Name: � . � �:�. <br /> Phone (day): ` '��" <br /> Address �,`j ~�j % City: U��C� ZIP: s � � <br /> Email and/or Fax �� <br /> PROJECT INFORMATION: <br /> � <br /> Type of Project: Any earth movement may require <br />��� MCWD review&permits: � <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage Minnehaha Creek Watershed District(MCWD) �' <br /> � <br /> -roof,asphalt ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd - <br /> ❑ Re-roof,cedar ❑ Restoration Deephaven, MN 55391 `' <br /> ❑Water Damage � <br /> Phone: 952-471-0590 � <br /> ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 � <br /> ❑Window(s) <br /> www.minnehahacreek.orq rr� <br /> >�: <br /> Overall Project Description: 4� <br /> Estimated Construction Valuation of Project(excluding land) $ �• <br /> _�� <br /> ;;� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> � <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 /> `� <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 /> purpose and intended use of this information is to annually update our records and records of other governmental agencies � <br /> re uired b law. If ou r fuse o su I the informati n,the a 'cati ma not be issued. <br /> ; �'-. <br /> ApplicanYs Signature: �� Date: /� �>�/ � <br /> � <br /> Last Updated: 08-09-2011 ;�, <br /> ..; <br /> 1_ __... ._ __ .. .. . . .. . yA� <br />