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I <br /> ' � City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> /�� � �, Mailing Address: Permit number: �O/ —D� 7 <br /> � �0�1%� Po BoX 66 —�— <br /> � Crystal Bay, MN 55323-0066 Date received: �� J�� <br /> ( ' Received by: V L� <br /> ` � Sfreet Address: <br /> `y � �% 2750 Kelley Parkway Plan review fee: <br /> �`�t �`�'� Orono, MN 55356 <br /> �Kf.SHUQ'.� � ��. /� <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: <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 applrcant demonstrates sufficient on-site parking is available. Non-permifted events wi�l not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> ` L <br /> Name: : � . vne.��� �T � v� �o �� L L- <br /> State License# � G b C� �3/e Expiration Date: � ��� <br /> Lead Certification Number: � � �-- j� � � � Z — / �jj�jd u�/Expiration Date: <br /> (for woik on homes that were consfrucfed prior to 1978 <br /> Phone: (cell) �j( 2. ��/7 Z'3��; (office) <br /> Mailing Address: / " , / ` ,� �,,�� City: l,�y `�N P�,���r ZIP: �� r�,- 3�S` <br /> Contact Person: � �u,�� � S�',,,��, �2 Applicant is: Contracto / Homeowner (Ci►cleOne) <br /> Email and/or Fax: cl r s s��c�.� ![�:.-�'� r�.��•�5/L. �C7` Fq,c �S�Z `%�3 �" oo �� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � �,'k y f- � a� �v��,����s a:� <br /> Phone (day): ��Z 3p c� !�C � y <br /> Address: �{ �p Cn � City: ..�� ,,��, ZIP: -� 3 S 6 <br /> Email and/or Fax: e, ��t u L b �^�hrf5o" �;;J G;,�,,"/ , �,� <br /> PROJECT INFORMATION: Overall pro�ect descri tion: <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) (�.Remodel ❑ Fire Damage <br /> MCWD review 8�permits: <br /> Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt ❑ Repair ❑ Storm Damage 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) www.minnehahacreek.ora <br /> Estimated Construction Valuation of Project(excluding land) $ 2 c, �p0. <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 the information,the a licati ma not-�e issued. <br /> ApplicanYs Signature: �`�.. Date: Z � �G � <br /> ; <br /> Owner's Signature: / Date: <br /> Last Updated:03/O6/2013 <br />