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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 /> Vo A PO Box 66 Mailing Address: Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> � � 2750 Kelley Parkway Plan review fee: <br /> ` 'rESHO��G Orono, MN 55356 <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: _26 /0 C r'S tq}Ar✓c e rJr"c'z _ c(-7//6 / <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: ,llc 0Jcei7 i,/7 8(Air(.r- /Cr <br /> State License# .8c- 6 t/,2 G g'.2 Expiration Date: 3/-1 <br /> Lead Certification Number: Mr-//8973 -- / Expiration Date: !/- <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) s-2 - ..2/.2 y66 (office) p'S 2- .2/2- /766 <br /> Mailing Address: /WA) City:.syr<,1r'e/c„' ZIP: 3-s-.3-7C <br /> Contact Person: �o/,,, /'7c Applicant is: �ontracty / Homeowner (Circle One) <br /> Email and/or Fax: I cin 6-) Ai.6>c ccs cell t S'c9,I Re; c c^V,2 <br /> PROPERTY OWNER INFORMATION: <br /> Name: CMcly F pJ4' <br /> Phone (day): / -- 3��- /Y;6 <br /> Address: 7.6/0 Lif s--t Z y-ye Ac-,,/ City: p/;, ZIP: 53:3 ( <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Overall project description: / S .me/Z.` An//3-4 ivct..‹ <br /> Type of Project: Any earth movement may also require <br /> ❑ Door(s) 0 Remodel 0 Fire Damage MCWD review&permits: <br /> ❑ Re-roof,asphalt 0 Repair 0 Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 18202 Minnetonka Blvd <br /> 0 Re-roof,cedar Restoration 0 Water Damage Deephaven, MN 55391 <br /> ❑ Re-roof,other(specify) 0 Siding 0 Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ :S"i; cc'c "=- <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/ e ap•lication may not be issued. <br /> Applicant's Signature: - (� - �' '�3-� Date: <br /> Owner's Signature: Date: <br /> Last Updated: 03/06/2013 <br />