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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 Mailing Address: a���.� �((LoQ <br /> PO Box 66 Permit number: <br /> � �� Crystal Bay, MN 55323-0 Date received: �O' g� 2a <br /> �. � <br /> Street Address: \ Received by: <br /> 2750 Kelley Parkway 1p �� Plan review fee: <br /> � "� Orono, MN 55356 <br /> `qkFSHv�� Total Fee: ��jl�, �3 <br /> Main: 952-249-4600 Fax: 952-249-4616 www ci oronc rr�n us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 2, p - � —� � r+ � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> If yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the evenf. Shutt/e bus rvicLawill be <br /> required uMess applicant demonstrates su�cient on-site parking is availab/e. Non permitted events will not be al/owed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 'NEQ �T �E .���"D r <br /> State License# �� ��-3i� Expiration Date: d -� <br /> Lead Certification Number: ��M„� 'gu�..` ,,•, 2oa'Z Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) �5�1 457- 52loS (off�) `'1 SZ- 92"l- (a5�� <br /> Mailing Address: � �,�,.`q,� � City: � v� ZIP: � � <br /> Contact Person: �KF, �a���E,� .�,��� Applicant is: / Homeowner (Circle One) <br /> Email and/or Fax: �� p H���-T ocl�.� �3 `,�Y�� ��,Y� <br /> PROPERTY OWNER INFORMATION: <br /> Name: Rn+:�SZE� ��L1,S <br /> Phone (day): "]�3 — �{ya- �y(o0 <br /> Address: Z Q�5 5v�e 5�-r �_�r�� C�tY� ��� �v c� ZIP: S'S 3S (p <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall ro�ect descri tion: <br /> Type of Project: � Any earth movement may also require <br /> ❑ Door(s) Remodel ❑ Fire Damage MCWD review�permits: <br /> � ' Minnehaha Creek Watershed District(MCWD) <br /> ❑ Re-roof,asphalt air ❑Storm Damage <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.orp <br /> Estimated Construction Valuation of Project(excluding land) $��� <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 lication ma not be issued. <br /> ApplicanYs Signature: -_�- w ��� Date: i(7 2 0 l�' <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />