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1 <br /> City of Orono <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> �0 Mailing Address: <br /> PO Box 66 Permit number. <br /> Crystal Bay, MN 55323-0066 <br /> Street Address: Received by <br /> F ` 2750 Kelley Parkway Plan review fee..; <br /> Orono, MN 55356 <br /> �kFstio� <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 /> GENERAL INFORMATION: /� <br /> Job Site Address: /I 5 Tonle—' t wa- /�-GC <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 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: <br /> State License# 109 Expiration Date: <br /> Lead Certification Number: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) 1?5,;Z —,,;2-77 <br /> Mailing Address: D t?16.1(Ili 13/yA, City: p ns ZIP: �5_5343 <br /> Contact Person: Applicant is: tracto 5 / Homeowner (Circle One) <br /> Email and/or Fax: L� j V1SIMfStrQ ,5C(/tki1�-2V 1^OC, COP,-, <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone(day): _ ,� .01 <br /> Address: I1 O q T211ka f!ri k6acq City: wCl (�ZA-�Gl ZIP: _513 1 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: <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) $ <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 the application may not be issued. <br /> Applicant's Signature: Date: <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />