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C'J"' , �� <br /> City of Orono 3-�3 <br /> ' Building Permit Application for Maintenance / Renovation �� <br /> (windows, doors, siding, re-roof, etc.) �{ZS• 5� <br /> Mailing Address: Permit number: o��/c� - OC� � <br /> O�,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 3-1 2-�2 <br /> � _ a, Street Address: Received by: 6-�� <br /> �' �° �� ti�' 2750 Kelle Parkwa '/� <br /> � � Y Y Plan review fee: �!o�, T <br /> L9kE8H��`'� Orono, MN 55356 <br /> - Total Fee: �D/a- D D/�� <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 returned. (Please print) <br /> GENERAL INFORMATION: 'J ^� � � � <br /> Job Site Address: [ ..� r Y'��� rDvt�.'� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f yes,a specia/event permit is required with Police Department and City Counci/approva/60 days prior to the event. Shutt/e bus s rvi e wi//be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP ICANT INFORMAT ON: <br /> Name: ��C �� �av✓�✓1 L�� "—�J�� <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (office) Cj�p�a,,f"� — S7�U (cell) <br /> Mailing Address: S"� �-K n�_ City: `S�(, <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF MATION: <br /> Name: ���� c�,���/ <br /> Phone (day): J _ — 5�7 7 U <br /> Address: � � ,r;V� City: �v—c� ZIP: `��3� <br /> Email and/or Fax ,� Kc�v��y �IMG 5��� G� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review&permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> ❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof, other(specify) Siding ❑ Other: (specify) Fax: 952-471-0682 <br /> indow(s) www.minnehahacreek.orp <br /> Overall Project Description: �.od.c�� �--��--t c�—� <br /> Estimated Construction Valuation of Project(excluding land) $ a�,p4�.-p-� <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 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 th� formation is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou refuse t su I the infor tion, the a lication ma not be issued. <br /> ApplicanYs Signature: Date: �2 <br /> Last Updated: 08-09-2011 �Z <br />