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<br /> C i�y of O ro n o � � �` �� �� °�� � � ��
<br /> ;
<br /> . � Building Permit Application for Maintenance / Renovation �g
<br />�.: �
<br /> (windows, doors, siding, re-roof, etc.)
<br /> Mailing Address: `
<br /> ` -gv 0,� PO Box 66 Permit number. :
<br /> � �. 0
<br /> Crystal Bay, MN 55323-0066 Date received:
<br /> �
<br /> ..n �,.
<br /> a a � s, � Street Address: Received by: �
<br /> �� ��� ti 2750 Kelle Parkwa �
<br /> � o y Y Plan review fee:
<br /> t9'kESH��� Orono, MN 55356 �
<br /> Total Fee: t
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �'
<br /> ,,:�<
<br /> This application form must be completed in full and all required information must be submitted. rv�
<br /> Incomplete applications will be returned. (Please print) �
<br />� GENERAL INFORMATION: ��
<br /> �
<br />�F Job Site Address: l�-�..� �- v�✓'� � � !.-,U �
<br /> � Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No �
<br />; If yes,a special event permit rs required with Police Department and City Councif approval 60 days prior to the event. Shuttle bus serv e will be �,
<br />''' required unless applicant demonstrates sufficienf on-site parking is available. Non-permitted events wifl not be allowed. �
<br /> �..a
<br /> ��
<br /> CONTRACTOR/APPLICANT INFORM TION:
<br /> Name: � G V�i�lCi � 0�'1N�' �
<br /> �-; State License# Expiration Date: �
<br /> Lead Certification Number. Expiration Date: ��
<br />�
<br /> (for work on homes that were construcfed prior fo ?978 i;;
<br /> Phone:
<br /> (office) ��a S�--S��O(cell) �
<br /> Mailing Address: � S3 ��-k y�,� City: ,.� ZIP: S��(D � ��
<br />,,�, Contact Person: �� ��h� Applicant is: Contractor Homeowne �'
<br />� (Circle One) �
<br />�. Email and/or Fax: �-� ��
<br /> �;�
<br /> � �a�
<br />�_,; PROPERTY OWNER FORMATION: ��
<br /> Name: ��� k -�,Q^-(/ �'i �i/ �
<br /> Phone (day): Ol ,� — ,S�— S 7U � �
<br /> £�.
<br /> Address: (C-C,f'� �C_ ,��_ City: �%�i"1�1�.� ZIP: S�� �y ��
<br /> Email and/or Fax � (�c�✓����/ �Q ,G�C .S����J� �`
<br /> f �
<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 /> �
<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 /> Window(s) www.minnehahacreek.orq
<br />�,��
<br /> Overall Project Description: G.J/rlcl� S � �'/ /i
<br /> Estimated Construction Valuation of Project(excluding land) a ,�'j - ��
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all informafion 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 3:
<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 pubiic 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 refuse s I the information,the a lication ma not be issued.
<br /> �ApplicanYs Signature: �L -� Date: _j /Z�/� "�
<br /> ;,�
<br /> Last Updated: 08-09-2011 ;,�
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