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<br /> City of Orono �.� ,,�
<br /> B�ildi�g Permit Application for Maintenance / Replacement / Renovation ��
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) �
<br /> �O� Mailing Address: Permit number: �3 —� �
<br /> O PO Box 66 `
<br /> Crystal Bay, MN 55323-0066 Date received: `o�7�.3
<br /> :�f;
<br /> Sfreet Address: Received by: `
<br /> �
<br /> � � 2750 Kelle Parkwa
<br /> y�, G� Y Y Plan review fe : �
<br /> t Orono, MN 55356
<br /> �kESH��� ���• `Y�
<br /> Total Fee:
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us >t�
<br /> This application form must be completed in full and all required information must be submitted. ^:ti
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION: .
<br /> Job Site Address: � � � � � �.
<br /> I�C> 4�r ✓^� l��....� �
<br /> Will this be a Parade of Flomes, Remodelers Showcase Home or other Display Home? ❑ 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 service will be �
<br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> ,�,
<br /> >.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: ��1vv--� �`��-�-�� �— �-1��.�s.1� ������, ��
<br /> State License# �; C C, 3 �j ! ��, Expiration Date: ��, -��_ Z�> >5� �
<br /> Lead Certification Number: �,�— 3 `� �`�� -- 1 G —vc>Z i Z Expiration Date: ,i�_ jy- Zu j� -
<br /> (for work on h es that were constructed prior to 1978 �
<br /> Phone: -�(cell) G Z - �� l�3Z ( j (office) 7G 3 -5'�/�-( -- ZU l"�, �
<br /> Mailing Address: C��Z c� � 3, th L-� � City: �,,,�, ,,,,�-�-� ZIP: 5�5�(
<br /> Contact Person: ��,,, ,�.�.� Applicant is: ontra tor / Homeowner (Circle One)
<br /> Email and/or Fax: �� - ,, �c�� v.3 �.�, � ��,� ' � . �'v� tp
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: �;� '"�—�r� ��,� ';
<br /> Phone (day): �` �_�c� �5� �
<br /> Address: I'�c:.;`� 5��:;.-.:.,��,.-:� �"��.. City:�J,�.rZ.�.:. ZIP: � ��� (
<br /> Email and/or Fax:
<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 ❑ Other: (specify) Phone: 952-471-0590 �
<br /> �
<br /> Fax: 952-471-0682
<br /> '�Window(s) S.•.�ku.� www.minnehahacreek.orq
<br /> Estimated Construction Valuation of Project(excluding land) $ ' I' F�;G�� ��
<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 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 t rmation,the a licati a not be issued.
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<br /> ApplicanYs Signature:-���'����� ' � �- �--� � Date: � �— Z�� — �� i3
<br /> Owner's Signature: Date:
<br /> Last Updated:03/06/2013
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