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City of Orono <br /> B�Id'.;�g Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> ������A��'� Mailing Address: <br /> �� ��,y PO Box 66 Permit number. <br /> (,'� � Crystal Bay, MN 55323-0066 Date received: <br /> I Street Address: Received by: <br /> ,'� YF �l 2750 Kelley Parkway Plan review fee: <br /> ��kESHo��'� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 w•�w.ci.cronc.mi�.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: �5 � r ,��. �`� f{�t�L t�� l!YU�1 b , r��� �'�� -��3�?,.� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home? ❑ Yes � No <br /> /f yes,a special event permit is required with Po/ice Department and City Counci/approva/60 days prior to the event. Shutt/e bus service wi//be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: ' <br /> Name: ,��I ; �:t�i.�;���_ !�� k�j;�i�(I.CLtrti �L�� 2� � � <br /> State License# j=��„r7 �j ����-r.� Expiration Date: �3 j� � �� <br /> Lead Certification Number. L f��j�'�" Expiration Date: .� j� 11F;�_ <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) 7 �� � �t.��-�`�� <br /> Mailing Address: �� -r��' �Li������, ��� 1�,7� City:_s,j M j��,���/ ZIP: �S 3�� <br /> Contact Person: �/��u ��,�P Applicant is: `Contracto � / Homeowner (Circle One) <br /> Email and/or Fax: � �,,�, r.� C�- il')YI Y'l�t�r2'lC�, l Y��`�D Ti�:��7ta�- (�WI �-7 L����.z-`� � �c' �7 Y l-��"X-� <br /> � <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��;� !� -1�'� f('_-��t.'Y7 <br /> Phone (day): <br /> Address: � I r� (��,, �,..� �l City: �i �-�j t��� ZIP: ��;�� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro'ect description: <br /> Type of Project: Any earth movement may also require <br /> ❑ Do j ❑ Remodel ❑ 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 ❑ 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_or�c <br /> Estimated Construction Valuation of Project(excluding land) $ �' �, U L! %; � ' <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide atl 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 th information,the a lication ma not be issued. <br /> _. � <br /> ApplicanYs Signature: ��r- = / --�- Date: ��' � %-/�� <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />