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��� <br /> � �7 t <br /> � • -~ City of Orono <br /> Building Permit Application for IVla�ntenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ��q� Mailing Address: <br /> �VO PO Box 66 Permit number: / � <br /> Crystal 8ay,MN 55323-0066 Date received: <br /> Sfreet Address: Received by: <br /> tiF � 2750 Kelley Parkway <br /> �' Orono,MN 55356 Pian review fee: <br /> 1qkFs x o��' <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This appiication 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 /> JobSiteAddress: ��-4`�uv t`�`='' ,�„l3�, � ��7��, �,@J <br /> Will this be a Parade of Homes,Remodelers Showcase Home or other Display Home? ❑Yes � No <br /> 1f yes,a special evenf pennit 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 s�cient on-site paiking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT 1IVFORMATlON: <br /> Name_ �;�3�01.� J�. ^ <br /> �-�:=.> ���;�-;.�;-�-;.,�J <br /> State License# �y f,:�� a�f ` Expiration Date_ <br /> .� ���3�� 'a� <br /> Lead Ceriification Number= Expiration Date: <br /> (f+�r work on homes that uvere constructed prior to 9978 <br /> � <br /> Phone_ (cel!) ��g� ��}`�-s���:; (office) ��io�� �i�i _=�►� : <br /> Mailing Add�ess: �a r,� '$�lAi+� �e'. C�h'= 9"SA�i.e, t��1�i� ZIP: `�S�cj 4� <br /> Contact Person: ��� ��-��.o�b�g����` Applicant is: ont / Homeowner (Circle One) <br /> Email and/or Fax: �,n�:�����—�:A��=�..C'� � f ;���o +�`?� - � ,�,X <br /> e ..� - <br /> PROPERTY 01MdER INFORMATlON: <br /> Name: ,^,�� `►- ;:��:•e�U ���i.���_.�.SJ":>"�T�:�--� <br /> Phone(daY)= r a�;�; a ;`,-"�s�i o <br /> Address: 'i 45��1 �:j`�� ���� �J C�Y� ��;,� ��'�.� Z1P: rj j j�J t� <br /> Email and/or Fax: y_ L�;��,��j��U�,�� �Aoi.��.,� <br /> tJwW�. P..oJ4i1a:T.<e��LJ'c- �'�UJ����,�i <br /> PROJECT INFORMATION: Overall pro"ect description: RL'�"d�pi�- �1a�2� .�.»� �(z ��,�;e� �-��;,a���. <br /> Type of Project� Any earti�movement may also reyuire <br /> ❑Door(s) �Remodel ❑Fire Damage MCWD review�permits: <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-roofi other(specify) ❑Siding ❑Other:(speciiy) Phone: 952-479-0590 <br /> Fax. 952-479-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estirriated Construction Valaation of Project(excluding land) $ �' 7� <br /> � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> � Agrees to provide all informafion required or requested by the 8uilding Department; <br /> � Certifies that the information supplied is tn.ie and correct to the best of his/her Imowledge. The applicant recognizes that they are <br /> solely responsibie for submitting a complete application being aware that upon failure to do so,the staff has no altemative 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 generaUy cannof be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annuaily update our records and records of other govemmental agencies required by law. If <br /> ou reiuse to suppl the informaSon, pplication ma not be issued. <br /> ApplicanYs Signature: � Date: �!�����, <br /> r <br /> Owr�er's Signature: Date: <br /> Last Updated_03/06l20'!3 <br />