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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: Permit number: O�(�J�0 �Jc�p <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 � Date received: I6 - 30- G3 <br /> Street Address: Received by: � S <br /> y � 2750 Kelley Parkwa � l� �'a 3�3• uc � �`' <br /> Plan review fee: , <br /> �fqkFSH���,C' Orono, MN 55356 �� � �D�3 ��� 1�SS � <br /> Total Fee: �r' <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us fi, <br /> This application form must be completed in full and all required information must be sub itted. <br /> Incomplete applications will be returned. (Please print) �q,c�., � <br /> GENERAL INFORMATION: � / �'�� ; <br /> Job Site Address: �' '�l S -r- � � <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 s ice will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. '' <br /> CONTRACTOR/APPLICANT INFORMATION: j <br /> Name: �VI �'-�--cls-f-�{ ��f- �w� . ; <br /> ri7 <br /> State License# g� � � ,�� �� Expiration Date: �y�r�� �5- � <br /> Lead Certification Number: Expiration Date: ��� <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) ���- /� _ S- 5- (office) �; /� - S 5� } <br /> Mailing Address: �. � s- Cit : « ��--t- ��,� ZIP: -3 � � <br />� � Contact Person: J�t�/ Applicant is: ontract � / Homeowner �c��ae o�e� '� <br /> z.. <br /> F�' Email and/or Fax: �� ����,t.,e ������ ; � ? <br /> R-, t1 <br /> � <br /> r ` PROPERTY OWNER INFORMATION: � <br /> Name: � � c Q�•-�-«5�� <br /> Phone (day): (��1- 7/G -ys'j5� ` � <br /> Address: 35-�Si ,�h hC✓ /1/ , City�ra ��p ZIP: 5 `j >�3 ;. <br /> L4; <br /> Email and/or Fax: <br /> �:` <br /> ,k <br />'� PROJECT INFORMATION: Overall pro�ect description: <br /> Type of Project: Any earth movement may also require � <br /> - ❑ Door(s) �emodel ❑ Fire Damage MCWD review&permits: ; <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 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq P <br /> Estimated Construction Valuation of Project(excluding land) $ � `'s <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 informatio � �nually updat�ur r c and records of other governmental agencies required by law. If ''_ <br /> ou refuse to su I ' ormatiQrS�th li io ma i <br /> - 7 <br /> ApplicanYs Signature: Date: � - �� — � " <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />