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City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> OA, Mailing Address: Permit number: <br /> t YO PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 40-07—/ <br /> Street Address: Received by: <br /> 2750 Kelley Parkway Plan review fee: (� <br /> Orono, MN 55356 <br /> l�kEsHo 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 s mitted. <br /> Incomplete applications will be returned. (Please print) 07 / <br /> GENERAL INFORMATION: <br /> Job Site Address: \ C) 7O ny-,a W C^ R U J <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes TSo <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/APPLICANT INFORMATION: <br /> Name: i l <br /> State License# 16 C_ Expiration Date: <br /> Lead Certification Number: _ R-r- Expiration Date: 7 j -( � 15- <br /> (for work on homes that were nstructed prior to 1978 <br /> Phone: (cell) —a a - (office) 62 <br /> 3 _ 3 a(p <br /> Mailing Address: Co LA LA City: i ,A Co\ ZIP: --5 3 <br /> Contact Person: McAAA- Applicant is: on�ractor / Homeowner (circle one) <br /> Email and/or Fax: c� �J O5\�bN�\clefs . Lpr� <br /> PROPERTY OWNER INFORMATION: <br /> Name: Ckr `- \' PP C�e►„ <br /> Phone (day): I a —9 C -7 <br /> Address: l fh \ `S Trip�c1AIA.)C-- V-4C� City: G rcn \ cd ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description:_' VV\ �vlty \' 2� \Uc`r. <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) &Remodel ❑ Fire Damage MCWD review&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.org <br /> Estimated Construction Valuation of Project(excluding land) $ too/ 060100 <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 <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the e <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpos <br /> intended use of this information is to annually update our records and records of other governmental agencies required by <br /> you refuse to supply the i ormatio ,thellappliqation may not be issued. <br /> Applicant's Signature: Date: Z <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />