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<br /> City of Orono 5z5 ( �
<br /> . �
<br /> �� Building Permit Application for Maintenance / Renovation �
<br /> (windows, doors, siding, re-roof, etc.) �
<br /> �
<br /> �-- Mailing Address: �'
<br /> ��v�,� PO Box 66 Permit number: �
<br /> . � � � Crystal Bay, MN 55323-0066 Date received:
<br />� ���` Received b
<br /> .� �� � ���i;� �, ' StreetAddress: Y� ;
<br /> "' '�,� i �en, ti J 2750 Kelley Parkway Plan review fee: ,
<br />�� '��v�K�'o4 j� Orono, MN 55356 ;�
<br />�, --' Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
<br /> 'a��� This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Please print)
<br /> F � GENERAL INFORMATION: µ'
<br /> Job Site Address: �p�Ei f� .-,� � y�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �
<br /> ❑ No �
<br /> If yes, a special event permit is required with Pofice 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 /> �� �hF CONTRACTOR/APPLICANT INFORMATION:
<br />�:� Name: S�.�e r�:�� �c L L �_ �'
<br />�.; State License # �,�i�3���� Expiration Date: 1��3 �
<br />�� Lead Certification Number. Expiration Date: �
<br /> ��:
<br /> fiV (for work on homes that were constructed prior to 1978 �
<br /> � Phone: �; i2 �5'ic `> 7�'/ (office) �S,?_ S%3 - �'� �; 7 (cell)
<br /> �,.
<br /> Mailing Address: �.C7. jj�k� Z � City: ,n � ZIP: �-� 3 ;
<br />� ' Contact Person: Ju s�,11 ��;.; Appficant is: Contr ctor� / Homeowner (Circle One) c�
<br /> - �mail and/or Fax: `' �
<br />,x,: �
<br /> PROPERTY OWNER INFORMATION: /. ��
<br />`��� �
<br /> '� Name: �,'c,� f�i��flrsc+n
<br /> Phone (day): �Sy , 5�..; � DO�Z- .s-E, '
<br /> ' Address: �3v Pn .-,� L ,-, . City: r��� ZIP: �- '
<br /> V rc �2 c' � J�.
<br />� � Email and/or Fax
<br /> :;,�
<br /> : �
<br /> �� PROJECT INFORMATION: ��
<br /> Type of Project: Any earth movement may require `�
<br /> ❑ Door(s) ❑ Remodel MCWD review&permits: �
<br /> ❑ Fir Damage Minnehaha Creek Watershed District(MCWD) #
<br />�� �-roof, asphalt ❑ Repair Storm Damage 18202 Minnetonka Blvd '�
<br /> E; ❑ Re-roof, cedar Q"Restoration ❑Water Damage Deephaven, MN 55391 �
<br />�' Phone: 952-471-0590 ��
<br />�u ❑ Re-roof,other(specify) ❑ Siding ❑ Other: (specify) Fax: 952-471-0682 �
<br /> �; ❑Window(s)
<br /> www.minnehahacreek.orq �
<br />,,:
<br />�,; Overall Project Description: � _ /��� .{'
<br /> �a
<br />�
<br /> Estimated Construction Valuation of Project (excluding land) $ j�j��rL, �� �
<br /> � APPLICANT ACKNOWLEDGEMENT: �
<br />:�.:,,
<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 />,.,y but to reject it until it is complete; �
<br /> k �,'
<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 i'�
<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 /> �:�
<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 refus su I the information, the a lication ma not be issued. �
<br /> ;�:a;�
<br /> �
<br /> ApplicanYs Signature: Date: l� �- lf- Z- � // �
<br /> Last Updated: 08-09-2011
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