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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 Mailing Address: Permit number: o?���/f� <br /> � �O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Da#e received: /D oZ��`7� <br /> Street Address: Received by: <br /> y�, G�` 2750 Kelley Paricwa b a�t� Plan review fee: <br /> t Orono, MN 55356 � � � <br /> �x�sHa�� ��7. 53 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This apptication form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ,�2�5 SI}A�y lNbop �. G'�,oJUQ f �� S�s3°�, ( <br /> WIII this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wil!be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be al/owed. <br /> CONTRACTOR/APPLICANT INFOR ATION: � <br /> Name: �v J«k �S� H. TCec� '�'canl v 15�, <br /> State License# �L L���pS' Expiration Date: Ap�.`� ,?��� <br /> Lead Certification Number: .�. Expiration Date: ` <br /> (for work on homes that were constructed prlor to 1978 <br /> Phone: (cell) �2 - �� — �C.�t3 (office) �^ <br /> Maiting Address: 2��p Ck��y� �, City: }.�Y�,�, ZiP: s-S'3t{� <br /> Contact Person: � � � Applicant is: Contractor / Homeowner (Cirele�e) <br /> Email and/or Fax: -r-��,T r►�'�l qw�t �C�v1 <br /> PROPERTY OWNER INFORMATION: � <br /> Name: �}-y����,J St3�15�T�} <br /> Phone(day): �12 - 3��, _2�j� <br /> Address: 32CP R����� ��, City: � ZIP: �'s'3C�, <br /> Email and/or Fax: �b�„�. �,�St�c�qww+ .C,��^'I <br /> PROJECT INFORMATION: Overall ro'ect descri tion: �.c¢, 3� e� �- ro� ►'�'�i�u �"Sr4q�a <br /> Type of Project: My earth movement may also require <br /> ❑Door(s) ❑Remodel ❑Fire Damage ��WD revlew&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 /> 12{�`4.� �tG�c.. Fax: 952-471-0682 <br /> ❑Window(s) � www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or r uested th uil i , <br /> • Certifies that the information supplied is fiu and c ct to the best of his/her knowledge. The appticant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon fai►ure to do so,the staff has no altemative 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 class�ed 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 the i ion lication ma ot be issued. <br /> Applicant's Signature: Date: IO �I 0� • <br /> Owner's Signature: � Date: 10%)�zd 1`� <br /> Last Updated:03/O6/2013 <br />