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c <br /> . - <br /> ' . C ��1I�� <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> a Mailing Address: PeRnit number: � 3 <br /> 4� h�� Po BoX 66 5 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> y � 2750 Kelley Parkway Plan review fee: , <br /> 'F' G <br /> t Orono,MN 55356 <br /> '�KFs�o�� a� b � <br /> Total Fee: <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 retumed. (Please print) <br /> GENERAL INFORMATION: „^ -,^ <br /> Job Site Address: 5 � ,D YG )� 1 �) <br /> Will this be a Parade of Homes, Remodele s Showcase Home or otlaer Display Home? Yes ,�Wo <br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrafes su�cient on-site parking is availa6le. Non-permitted events will not 6e allowed. <br /> CONTRACTOR/ LICANT INFORMATION: <br /> Name: ,r, � I� <br /> State License# Expiration Date: - J- <br /> Lead Certification Number: °�75'��- � Expiration Date: L,J•`'j� ��f� <br /> (for work on homes that were constructed'prior to 1978 � <br /> Phone: (cell) (office)� , � <br /> Mailing Address: �.- City: ZIP: <br /> Contact Person: Y, Applicant is: o rac or / Homeowner �ci���e o�e� <br /> Email and/or Fax: A/ S/C U�`!' <br /> PROPERTY OWNER INFOR ATION: J���� � <br /> Name: �A_1"L�l w Q�7� � O/�P''� � <br /> Phone(day): <br /> Address: City ZIP: s,.,s <br /> Email and/or Fax: M�r , � � <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑Door(s) ❑Remodel ❑Fire Damage MCWD review 8�permits: <br /> ❑Re-roof,asphalt ❑ Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specify) ❑Siding ,Q�Other: (specify) Phone: 952-471-0590 <br /> � , � r/�� Fax: 952-471-0682 <br /> ❑Window(s) /� .�y� www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ , " <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 are <br /> solely responsible for submitting a complete apptication being aware that upon failure to do so,the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is Gassified 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 data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other govemmental agencies required by law. If <br /> ou refuse to su I information, e a lication ma not be issued. <br /> ApplicanYs Signature: �� Date: �� � <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />