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r � <br /> City of Orono <br /> Buil ing Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> O� Mailing Address: Permit number: �� — <br /> O PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: �Z" <br /> Street Address: Received by� <br /> y � 2750 Kelley Parkway Plan revie ee: <br /> `�tq �,� Orono, MN 55356 <br /> fSHUR �� '�j 9�� <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 /> GEN L(NFORMATION: <br /> Job S te Address: �Oso SvsS �C'/� / <br /> Will t is be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ' No <br /> If y s,a specia/event permit is requrred with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not 6e aflowed. <br /> CON RACTOR/APPLICANT INFORMATION: <br /> Nam : �jrrf� ,adi���.�� �`'s-�'Ta`�_ <br /> State License# ��•'�3'iG yp Expiration Date: p,3 �i a�i� <br /> Lead ertification Number: �,�T ^�7v7Ci —/ Expiration Date: p�� � ��,� <br /> (f work on homes that were constructed prior to 1978 <br /> Phon : (cell) ����� 6�6 - �Sa G (o�ce) ���j� %�€-G��o / <br /> Maili g Address: /�- iv �� ss� C�tY� �Ys���/ ZIP: ss-yy <br /> Cont ct Person: �f�.�` i3, L-�<<f�,yt�c�>� Applicant is: ontrac o / Homeowner (CircleOne) <br /> Ema' and/or Fax: ,r��<<��s�yE<<�� Q° jf.��-,.`z./��.�n.-- C c-s�,..-trrr . c�-,.--L. <br /> � <br /> PRO ERTY OWNER INFORMATION: <br /> Nam : l'�i✓�e�i�� ,�`�'��S <br /> Pho e (day): ��.�) 31 s - �3 so �,c�, <br /> Add ss: �o � G•�� ,P��� P� , City:�`�„�6l /�l1 i ZIP: �7fi 7 <br /> Em I and/or Fax: <br /> PR JECT INFORMATION: Overall ro�ect descri tion: <br /> Typ of Project: Any earth movement may also require <br /> ❑ oor(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits: <br /> ❑ e-roof,asphalt ❑Repair ❑Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> ❑ e-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391 <br /> ❑ e-roof, other(specify) ❑Siding ❑Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> [j�'Window(s) r�t s��r �,,,w�+.6s www.minnehahacreek.orq <br /> Es mated Construction Valuation of Project(excluding land) $ S"o ys' <br /> AP LICANT 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 /> Ap IicanYs Signature: .�� /�� Date: �' �' �S� <br /> O ner's Signature: Date: <br /> La Updated:03/O6/2013 <br /> il <br />