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. City of Orono <br /> B�ilding Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> n O�O Mailing Address: Permit number: <br /> � PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> � �` 2750 Kelle Parkwa <br /> �'F Gti Y Y Plan review fee: <br /> Orono, MN 55356 <br /> ��KESHO�� <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) <br /> GENERAL INFORMATION: D <br /> JobSiteAddress: p,�, �/_ ����,,�l�v� �o�c� �rar�v ;/�� S��T �� <br /> Will this be a Parade of Homes, Remodelers S owcase Home or other Display Hom ? ❑ Yes �No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus se- rvice will be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ��'�'n if'✓.l f�,c�'/�e/S �izC. <br /> State License# /�C �'//�76 Expiration Date: ,.3 -,�/ _ /� <br /> Lead Certification Number: ��,,� Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (ce11) �fj_�j�� _//�� (office) �S/-�/,z R '!/�3 <br /> Mailing Address: �3 c/p � 7�i �rf.��/ City: � ZIP: ,syp � <br /> Contact Person: �, �`�- �',-���.cx Applicant is: � ontrac / Homeowner (Circle One) <br /> Email and/or Fax: ���- �,c� 3v �i�y�% ����r�/ , C��.� <br /> PROPERTY OWNER INFORMATION: <br /> Name: /'����` Lc//l��/�� <br /> Phone (day): gs-a - ���_ �99/ <br /> Address: �c."o: �/ S/��c�ss�l�r.�r��� �f�� City: �i.�'ar� ZIP: �'S 3�� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project 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 ,�Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) ��e,y'k�/ rC'✓!�il��C www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ � ,���ri' <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 knowfedge. 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 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 governmental agencies required by law. If <br /> ou refuse to su I the information,the a licatio ma not issued. <br /> �- ; , <br /> ApplicanYs Signature: • .-� l .. Date: g�� /—���`� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />