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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> • • (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O�O Mailing Address: Permit number: - <br /> PO Box 66 RECEIVED �� <br /> Crystal Bay, MN 55323-0066 Date received: /�L <br /> StreetAddress: SEP � O ZO14 Received by: <br /> � fi 2750 Kelle Park <br /> ��`' c, Y ��TY OF ORONO Plan review fee: <br /> ! ti Orono, MN 55356 <br /> �kESH�� �� � � <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 returned. (Please print) �z� <br /> GENERAL INFORMATION: � � <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a specia/event permit is required with Police Department and City Council approva/60 days pnor 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 /> G�� LIC ITNA NFORMATION• <br /> Name: <br /> State License# Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were cons ucted prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: Sy0 0 FAIWI�R� �� City: ��� ( -� ZIP: ss ��1 <br /> Contact Person: �.1 Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ���-�(t� � p� � ��p,p. Con <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): ,. .- � <br /> Address: �f S p City: ZIP: <br /> Email and/or Fax: D . <br /> PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&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 ❑ ther: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> �Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ . D <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 application 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 classified by State law as either private or <br /> confidential. Private data is inform tion hich generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information i h nerally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this informa' is nually update our records and records of other governmental agencies required by law. If <br /> ou refuse to su I the in mat' he a lication ma not be issued. <br /> ApplicanYs Signature: Date: <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />