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A. City of Orono <br /> Builb'Ing Permit Application for Maintenance / Replacement 1 Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �O1V Mailing Address: Permit number: - l!J <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: C� - <br /> Street Address: Received by: <br /> tiF L~ 2750 Kelley Parkway Plan review fee: <br /> ESHO Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us J <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: H Ss To0 ry <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes VNo <br /> ff 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 sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: IV.e Cvowr. Co�•�r( r�cf,�,,, 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) 61-L - E(65 — I b`(c� (office) <br /> Mailing Address: S2.L{vk G0Qr_, "l e tZ A City: Vv� hJZIP: 0% S 2z <br /> Contact Person: ,/V\L 1, hne rve-,Z Applicant is: ontract / omeowner (Circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: N) S,y \Z", <br /> Phone (day): 6(2 — -120 _ 2Z TLE <br /> Address: y 51: ?,,)v.k(_�L w� IZ� . City: C-)ypv.o ZIP: S <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: Re,ti..>y St_UR9fi+CC) Ilse,' <br /> Type of Project: Any earth moveme ay also require <br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt R-R-epair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD) 2 <br /> 18202 Minnetonka Blvd ro�5 <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.org <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 /> you refuse to supply the information,thea is ion may not be issued. <br /> Applicant's Signature: _ Date: 10/0-3 C' 2x14 <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />