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City of Orono /I 5D?'75" <br /> Building Permit Application for Maintenance / Replacement / Renovation <br /> ' (No structural expansion. Only windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: B _ e(' <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address: Received by: <br /> .� 2750 Kelley y� y Parkwa Y Plan review fee: <br /> �AkESHO�� 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: ( "-% Z {� V <br /> Will this be a Parade of Homes, Remodelers Sho case 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 seifvic6 will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: ,/ ,, C _ <br /> Name: �-�'UY fLS\f`( c.cJ-7� �' 1r V•l ca— G <br /> State License# Expiration Date: <br /> Lead Certification Num r: Expiration Date: <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) (office) <br /> Mailing Address: un p City: (,9�C, ZIP: 5-,E39 L <br /> Contact Person: Applicant is: Contract / Homeowner (circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: Q f—O nc AA t YL I S� r-a!E�- LL C•, <br /> Phone (day): !15-2- fl.L}- 2 D 1 9 <br /> Address: I X::1 (y1 p Dr- City:ELL 81211! Zlp: <br /> Email and/or Fax: OA <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) E] Siding Other: (speciPhone: 952-471-0590 <br /> ?,J .5Fax: 952-471-0682 <br /> E]Window(s) T�r(d 'r)IS4� J i www.minnehahacreek.org <br /> Estimated Construction Valuation of Project(Acid <br /> ing 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 i tion is to annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supW the inf mation,the application may not be issued. <br /> Applicant's Signature Date: <br /> Owner's Signature: Date: <br /> Last Updated:03/06/2013 <br />