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� <br /> � s N T� <br /> Cit of Orono 3 - � ��-;��� <br /> Y � 7"' <br /> lc � <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> � ,�'�� j ,^ Mailing Address: Permit number: o� -� S <br /> �' ����t},� PO Box 66 <br /> � Cr ystal Ba y, MN 55323-006 � Date received: —��—� <br /> Sfreet Address: I y�. Received by: �5 <br /> `��, �` 2750 Kelley Parkway � �In��� Plan review fee: �D�� - O b7 Z <br /> ,�r,q .�� Orono, MN 55356 � aao.s1 <br /> kE fi���r <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. (P/ease print) <br /> GENERAL INFORMATION: /^�� ��I^(^ S � � ' 1 �� q f <br /> Job Site Address: t[� t'JCJ "«.� / U <br /> Will this be a Parade of Homes, Remodelers Showcase Home or ofher 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 service will be <br /> required unless applicant demonstrates su(ficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORM TION: <br /> Name: J c7�1n ��C�� <br /> State License# Expiration Date: ,� <br /> Lead Certification Number. —� Expiration Date: — <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 6 - - 'j� (office) <br /> Mailing Address: b5 UbbS City: p ro�� z�P: 535� <br /> Contact Person: D1�,n � �,; Applicant is: Contractor / omeowne (Circle One) <br /> Email and/orFax: �(�� ���) �ol � -f-�nL, Co�►'� _ <br /> PROPERTY OWNER INFORMATION: <br /> Name: �'ah� Li¢h � <br /> Phone (day): ��3 -2-rb - 3 9'71 <br /> Address: p {-�.y (Lc� City: �1'�rl p ZIP: �j�j3 <br /> Email and/or Fax: � l �_ �� � ��� �D� <br /> PROJECT INFORMATION: Overall pro�ect description: <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) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ �.a1060 <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 qenerally 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 i mation, the a plication ma not be issued. <br /> Applicant's Signature: Date: � y <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />