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C��a-�.�., ���� �`� <br /> j � � � � /5 � �� ��° <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �0�� Mailing Address: Permit number: � <br /> PO Box 66 <br /> ��- 3 <br /> Crystal Bay,MN 55323-0066 Date received: �— <br /> Street Address: Received by: _� <br /> ��, G.� 2750 Kelley Parkway Plan review fee: p?�� 7—� <br /> l,pk�s�a��, Orono, MN 55356 97Q 3� �O <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: <br /> Job Site Address: ��Y� li7�► ��i �D <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 approval 60 days prior to the event. Shuttle bus service wil/be <br /> required unless applicant demonstrates su�cient on-site parking is availab/e. Non-permitfed events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: STtiu 1 k c 1--L-� <br /> State License# ��� c� -7 7D Expiration Date: 3/ � <br /> Lead Certification Number: �y9.7-� ��-�9•1.,� Expiration Date: 7 �j <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) � a (office) <br /> Mailing Address: a7 C /- Ci : �s��y� ZIP• v <br /> Contact Person: ,JD�j� Applicant is: ontr r / Homeowner �ci��ie o�e� <br /> Email and/or Fax: ?�3 i,��.-C-�► � 7 <br /> a-z� <br /> PROPERTY OWNER INFORMATION: <br /> Name: JoH��f� w����l o al <br /> Phone (day): 6/a $v 3 • /3 _� k�,,� <br /> Address: ��yrS� C�(,y �� G City:�iPrQA7 O ZIP: S',5��`G <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro'ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑Door s �Remodel MCWD review&permits: <br /> ( ) ❑Fire Damage <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> ❑Re-roof,cedar 18202 Minnetonka Blvd <br /> ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other:(specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> .I�����1 ���'�'�1� �Window(s) www.minnehahacreek.orp <br /> Estimated Construction Valuation of Project(excluding land) $ v — <br /> APPLICANT ACKNOW�EDGEMENT: <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 infor ation is to annually update our records and records of other govemmental agencies required by law. If <br /> ou refuse to su I the' f rmatio the a lication ma not be issued. <br /> ApplicanYs Signature: Date: y��� �3 <br /> Owner's Signature: Date: <br /> Last Updated:03/O6/2013 <br />