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>; <br /> � ,� 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 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> e'`' <br /> '� Street Address: Received by: <br />; � yF �� 2750 Kelley Parkway Plan review fee: <br /> �' Orono, MN 55356 <br /> ��'�FSH��� gI� �� <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. (Pleas print) <br /> GENERAL INFORMATION: _ry� ,_ ( �� <br /> Job Site Address: ��_� ��/E, ��� � <br />, = Will this be a Parade of Homes, 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/ LICANT INF RM TIO • 'r3 <br />�`���� Name: �1l�C.S/� r �IL <br /> State License# � e Sa l ( �-I' Expiration Date: b3-3 I-1 S <br /> Lead Certification Number: Expiration Date: � <br /> "'' (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �,�2 -oZto- �f�l-SS (office) s'Z . 9�-t � - Z°1 I �� <br /> � <br /> Mailing Address: �gj�jQ .�` City:�t� �,�i,q�E„ ziP: �53 4 <br /> Contact Person: � Applicant is: ractor / Homeowner (Circle One) � <br /> Email and/or Fax: e �� •Cprv� z <br /> ,;� <br /> PROPERTY OW R INFORMATION: /� <br /> Name: f�h� � ��� l_SU��� <br /> Phone (day): _ Qq -U��� ( <br /> Address: p �'�" �f� �-�(d,� City: Q�Zy-�f d ZIP: �53J�`, <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: d+`» �bd� A��� �� E RE:/'►a�t�- 6(�C— <br /> ` Type of Project: Any earth movement may also require <br /> MCWD review&permits: � <br /> ❑ Door(s) �emodel ❑ Fire Damage � <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 c� <br /> Fax: 952-471-0682 d� <br /> ❑Window(s) www.minnehahacreek.orq �� <br /> � <br /> Estimated Construction Valuation of Project(excluding land) $ �• �d � <br /> � <br /> ' APPUCANT ACKNOWLEDGEMENT: <� <br /> • Agrees to provide all information required or requested by the Building Department; ;;� <br /> =,r <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 /> � <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 inf rmation e a lication ma not be issued. <br /> Applicant's Signatur : Date: �' 0?'� 3 <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />