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<br /> City of Orono 'a �b� .��
<br /> Building Permit Application for Maintenance / Repiacement / Renovation
<br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.)
<br /> �OA,O Mailing Address: Permit number: 1Q0 3 ` D�2 $
<br /> �V PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: t �'Z7-�.3
<br /> ,� � Street Address: Received by: �6J
<br /> 5 � 2750 Kelley Parkway Plan review fee: 6�
<br /> �lqkESN���G Orono, MN 55356 �,��3_ Q)Z,
<br /> �: �3, ,� P d .�
<br /> Main: 952-249-4600 Fax: 952-249-4616 v✓v:�.N,ci�rono,mn us
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be retumed. (Please print)
<br /> GENERAL INFORMATION: - .� C - �� , f
<br /> Job Site Address: �<_l��C� � �i S 5 c_�C 1��>�� �-� , j.���.�� �_��. �--�
<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 wRh Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> r�quired unless applicant demonstrates sufficient on-site parking is available. Non-permitted ev�ents will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: UJ i 1� c �G.�-• ���
<br /> State License# �G z�,,7��Z Expiration Date: 3 3 i i S
<br /> Lead Certification Number: Expiration Date:
<br /> (for work on homes that were constructed prior to 1978
<br /> Phone: (cell) lQ lZ. - 3`((�" (;;7 Z S3 (office)
<br /> Mailing Address: i�-� L 3 f�{�.��^-�-���-� �-::.�� C�tY� lti���nn�-��-F-��. ZIP: ��3y 5-
<br /> Contact Person: � � �, ��i,��„� Applicant is: �Contractor�`� Homeowner (Circle One)
<br /> Email and/or Fax: �,',�� �w �� � � ���,,,,��� , � � L..�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: � �:S��-� ��,,.,.( _�__�c s 1 � � lLc t l�
<br /> �..
<br /> Phone(day): � �Z - y�� - 3 g 5��
<br /> Address: 2`l`1� 5�s s-2 x Z.:S. City: L����...1e--� ZIP: `a 5 3 .S �.,
<br /> Email and/or Fax: ;�;��,� , c o r�-� ;l�:�; �il �;.�.�i� I � r�.��.
<br /> PROJECT INFORMATION: Overall ro'ect descri tion: ��•c; c;,^ �,,<�'w ,�w.:,n-C��_-- i��;�^� r%-� � �.;ucc�'� i��.?�:r -�
<br /> Type of Project: Any earth movement may also require j"��''��'�
<br /> ❑ Door(s) �Remodel ❑ Fire Damage MCWD review 8�permits:
<br /> Minnehaha Creek Watershed District(MCWD)
<br /> ❑Re-roof,asphalt ❑ Repair ❑ Storm Damage 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) ,� �����_ �, ;�- � ,�,;;� or:-
<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 altemative 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 Gassified 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 annualty update our records and records of other govemmental agencies required by law. If
<br /> ou refuse to su I the information,the a lication ma not be issued.
<br /> Applicant'sSignature: ����-��- t"-�'��'=��`-`�---- Date: �� �7 /3
<br /> Owner's Signature: Date: ����� ��3
<br /> Last Updated:03/06/2013
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