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. �m �-3o - �y <br /> � <br /> C i ty of O ro n o a.l� <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O Mailing Address: Permit number: � -��J?� <br /> PO Box 66 <br /> � � Crystal Bay, MN 55323-0066 Date received: ���- / <br /> Street Address: Received by: <br /> y G� 2750 Kelley Parkway Plan review fee: ��O•oZ.� <br /> �`�'rf S H O�� Orono, MN 55356 � �3� <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: �300 vt�G �lA.c.�, Ovo r�o M/`� �5 3 L� <br /> Will this be a Parade of Homes, Re odelers Showcas Home or her Display Home? Yes No <br /> lf yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will 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: p p �^1 L. <br /> State License# (3G G-y9 2�f3 Expiration Date: 3 3 � � <br /> Lead Certification Number: Nl4-�= �1�-t i 2--� — ( Expiration Date: � $ <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (o�Z,��� ,�g-Z,r (office) 9SZ�449 ��d0b <br /> Mailing Address I�Zr3 g,,,.N �', ���p City: �� p�a,�y� ZIP: �- 3�},� <br /> Contact Person: M�q Applicant is: rC"orSt�Ctt7n / Homeowner �c�►�ie o�e> <br /> Email and/or Fax: �0 A.�7GGocooa -ln�fiv�1�'►� .�Ol�. �'JJ <br /> PROPERTY OWNER INFORMATION: <br /> Name: s"T�t�► +� C{�r+a.STI McL�hN <br /> Phone (day): �(�;- ZS-1_Zfj�p <br /> Address: �3pa SPr�LG ��,� City: dra�p ZIP: s5 3G� <br /> Email and/or Fax: �n�(,a,;H l3D0 � Msn• �ow.. <br /> PROJECT INFORMATION: Overall ro�ect descri tion: �� !M1'���►�� ��'^ �/+��''�� <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) ❑ 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) M�t.� r'oo�'+'1 �Z'►�`L www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ S, �'70.aO <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 �enerally 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: vt • Date: 7��0�L4l� <br /> Owner's Signature: Date: �� l 0 � 1 U <br /> Last Updated:03/06/2013 <br />