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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�O Mailing Address: i <br /> PO Box 66 Permit number: <br /> Crystal Bay,MN 55323-0066 Date received: � � <br /> Street Address: l Received by: � <br /> y GZ 2750 Kelley Parkwa al�'YI' Plan review fee: <br /> `� Orono,MN 55356 � � � <br /> l9kES HO�� ��/� <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: �'= ,/�vE. Q , �� �'1� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> !f yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service wil!be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: CTc�Oa►.� '�✓aµ6s Cc�.n-�dwG'�6aIUV <br /> State License# �,�,S3�q��� Expiration Date: 30 3��9� <br /> Lead Certification Number: �-- Expiration Date: �--' <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) CoS� �a�-�$1a�. (o��� �.��3� ��a-3�\� <br /> Mailing Address: S65q M,A,1t�� � City: Mqp�, p�.qo� ZIP: �j53S� <br /> Contact Person: �„q��- NGuSc,9�w��l�YC Applicant is:�on r" at—"c�o� / Homeowner (Circle One) <br /> Email and/or Fax: �A-��v .�,2,g��,-��LS C.c�M ^- (�� ���- �6�1� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �,paN �- l:n-��Ld�. C-��-'(3R.Po�N�S(NJ <br /> Phone(day): (qsz) G3�-3�4�-4`7 <br /> Address: ��c� �o� ,,t�v� � City: ��� ZIP: �j5 3S� <br /> Email and/or Fax: g�q.,,C,-�yl��,��,�Sp�� ('_y..ti,q�� �� <br /> PROJECT INFORMATION: Overall ro�ect descri tion: ��( . 6� �� ���5�► 4�Y� ` dJ'nc-Sc�'�+t�o,x�.��c�! <br /> Type of Project: Any earth move nt may also require <br /> ❑Door(s) �E2emodel ❑Fire Damage MCWD review 8�permits: <br /> ❑Re-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> �Re-roof,cedar �Restora6on ❑Water Damage Deephaven,MN 55391 <br /> ❑Re-roof,other(specify) ❑Siding ❑Other: (specify) Phone: 952�71-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �.'S�CX3� <br /> — '6 n�,n,o_Q p�t,��,v�� v�/us� ��;r,�: <br /> APPLICANT ACKNOWLEDGEMENT: dp'O <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 prowlke 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 /> Confidenfial 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 information t e a lication ma not be issued. <br /> ApplicanYs Signature: Date: �'�J�'��� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />